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J3ABNEY, M.D., Professor of Practice of Medicine, &c, in the University of Virginia. IW VV i* Printed by the Charlottesville Jeffersonian for GEO. W. OLIVIER, ^£di'c ^ b oo k seller and stationer, .University of Virginia, -• 21162* Entered according to an Act of Congress, in the year 1N91, 1 >y WILLIAM C. DAliNEY, in the office of the Librarian of Congress at Wa.shington. PREFACE. This Abstract is not intended to take the place of a regular text-book on the Practice of Medicine, but merely to assist the student to a bettor under- standing of the principles of the subject of which it treats. I have therefore endeavored to make it ex- planatory as far as was possible in such a limited space. CHAPTER I. GENERAL PATHOLOGY. Definition. — General Pathology treats of the morbid conditions which are common to many different diseases. It is used in contradistinction to Special Pathology which treats of individual diseases. DISTURBANCES OF THE CIRCULATION. Anaemia. Varieties. — I. General, meaning literally a deficiency of the xvhole amount of the blood, but usually used to denote a deficiency of the red corpuscles. 2. Local, meaning a partial or complete arrest of the blood supply to a limited part of the body. General anaemia will be considered hereafter. Causes of Local Anaemia.— i. A diminution in the lumen of the artery supplying a part with blood; such diminution may be due to one of the following conditions: (i) disease ot the wall of the blood vessel, such as atheroma, calcification, or syphilis ; (2) pressure on the vessel from without by tumors, inflamma- tory exudations, &c; (3) pluggmS °f tne vessel (thrombosis and embolism) ; (4) Contraction of the walls of the vessels, due to cold, heat, ergot and other medicines, counter-irritation, &c. This contraction is usually brought about through the mediation of the nervous system. 2. Dilatation of the vessels in one part of the body causing in- creased flow of blood into that part and consequently a diminution in the amount of blood elsewhere. This is called collateral ancemia and is of very great importance from a therapeutic standpoint. Results.—The results depend on the part involved and on the nature of the obstruction, but the general results are : 1. Pallor, from deprivation or diminution of red blood. 2. Coldness, because little or no oxygen is carried to the tissues and less heat is formed, and also because the warm blood itself is present in less amount than usual, or is cut off altogether. 3. Defective nutrition, because the nutritive materials are carried in the arterial blood and a diminution in the quantity of blood causes defective nutrition and often atrophy. 6 PRACTICE OF MEDICINE. 4. Collateral circulation, if the artery above and below the ob- struction gives off anastomatic branches. 5. Infarction, if the vessel is a terminal one as in the brain, kidneys, lungs and spleen. 6 Necrosis or gangrene, when the blood supply is more or less completely cut off and certain germs gain access to the part thus deprived of blood. 7. Simple softening, when the Wood supply is more or less completely cut off and the germs do not gain access to the ana*mic part. Hyperemia. Definition.—An abnormally large amount of blood in a part or organ Varieties.—1. Active or arterial. 2. Passive, venous,, or mechanical. Active Hyperemia. Condition of the Vessels and Circulation.—The arteries are dilated and the blood flows more rapidly. Causes of Active Hyperemia.—A. Diminished resistance ofthe walls of the blood vessels caused by 1. Anything which weakens or paralyzes the muscular coat of the smaller arteries, such as (1) sudden removal of pressure, as in ascites ,- (2) warmth ; (3) Paralysis of vaso-constrictor nerves from pressure injuries certain drugs, as amyl and alcohol, reflex agencies and 'also dis- turbances of nerve centres; (4) exhaustion from fatigue or over stimulation. 2. Irritation of vaso-dilator nerves as in certain cases of neu- ralgia. B. Unusually great pressure in the vessels from increased force 01 the heart, which may be due to (1) exertion ; (2) certain stimulants, such as alcohol ; (3) certain diseased conditions of the heart (hypertrophy). C. Contraction of the blood vessels in one part of the bodv causing a dilation elsewhere. Hyperemia caused in this way is called collateral hypercemia." y Results of Active Hyperemia.—1. Increased heat andrednr*. from increased amount of warm blood and increased oxidation in the part. " ln PRACTICE OF MEDICINE. 7 2. Increased functional activity, from increased supply of nutri- tive materials and also from elevated temperature. 3. Possibly increase in connective tissue, if of long duration. Passive Hyperemia. Condition of the Vessels and Circulation.—There is an exces- sive quantity of blood in the veins and capillaries and the flow is retarded. Causes of Passive Hyperaemia.— 1. Those which diminish the vis a tergo, as (1) weakness of the heart from any cause; (2) any impediment to the circulation in the arteries, as loss of elasticity or diminished calibre; (3) pressure on the capillaries by exudations or by effusions ; (4) anything which interferes with the action of the valves in the veins as varicose veins, and certain affections of the thoracic or respiratory organs. 2. Those which directly interfere with the flow of venous blood through the veins, such as (1) pressure on the veins by the enlarged uterus, collections of fluid, new formation of connective tissue (as in cirrhosis of the liver), &c. (2) the plugging of a vein by a thrombus. (3) certain obstructive or regurgitative lesions of the valves of the heart. (4) certain pulmonary diseases (as emphysema) causing de- struction of blood vessels in the lungs and consequent ovei-disten- sion and dilatation of the right cavities of the heart and then of the veins. Results of Passive Hyperaemia.—1. Diminished velocity of blood current, due to diminished pressure behind or to obstruction in front. 2. Transudation of serum from the blood vessels into the tissues, the transudation being due partly to increased intra-vascular press- ure, but chiefly to a change in the vascular walls from defective nutrition, by which they are rendered more permeable. 3. Escape of red corpuscles from the vessels, due to the same causes as the transudation of serum, and pigmentation from the breaking up of these corpuscles and the deposit of their pigment in the tissues. 4. Hemorrhage, from defective nutrition of the walls of the vessels which in connection with the overdistension causes them to rupture. Hemorrhage from the stomach in cirrhosis of the liver is to be explained in this way. O PRACTICE OF MEDICINE. 5. Fibroid induration, due to the escape of white blood cor- puscles from the vessels and the formation of connective tissue. 6. Thrombosis, the coagulation being due to a change in the vascular wall from defective nutrition. 7. Necrosis, or Gangrene, from the action of the germs of pu- trefaction on a part whose vitality is very much below the normal standard, in consequence of a defective supply of arterial ox nutri- tive blood. 8. Atrophy, from an insufficient supply of arterial blood. 9. Collateral circulation, from enlargement of anastomosing veins above and below the seat of obstruction. 10. Diminished heat in the part from stagnation of blood and defective oxidation. 11. Livid color, from accumulation of venous blood. 12. Diminished functional activity from want of arterial blood. Dropsy. Definition.—The accumulation of fluid in the various tissues and cavities of the body; such fluifl having passed out of the ves- sels by simple transudation and not in consequence of inflamma- tion. Varieties.—1. (Edema, or dropsy of the connective tissue. 2. Anasarca, a generalized (jedema. 3. Ascites, dropsy of the peritoneal cavity. 4 Hydrothorax, dropsy of the thoracic cavity, &c, &c. Causes of Dropsy.—1. Excessive flow of fluid from the ves- sels due to (1) mechanical hyperaemia ; (2) a feeble and relaxed state of the vessels and tissues ren- dering the former more permeable ; (3) unhealthy condition of the blood which acts by rendering the blood more dilute and also by causing defective nutrition of the vascular walls ; (4) defective nervous influence (as in nettle rash) ; 2. Defective absorption by the veins and lymphatics in conse- quence usually of some obstruction to the flow through them. Physical Character and Chemical Constituents of dropsical effusions—1. Color, usually pale straA' color, rarely red from the presence of red blood corpuscles. 2. Consistence, fluid, and remains a fluid, differing in this respect from some forms of inflammatory exudate. 3. Chemical constituents ; the fluid contains albumen and salts but the fibrin factors are present in small amount, if at all Clinical Forms Of Dropsy.—1. Cardiac, from weakness of PRACTICE OF MEDICINE. 9 heart or valvular lesions leading to passive hyperaemia. Dropsy appears first, as a rule, in the feet and ankles. 2. Obstructive, (as ascites from cirrhosis of the liver) due to mechanical hyperaemia and transudation from the veins behind the obstruction. 3. Renal, from change in the quality of the blood which becomes more watery and thus transudes more easily, and also causes de- fective nutrition of the vascular walls. Occurs in loose tissues, as eyelids. 4. Cachectic, from weakness of the heart and impaired nutrition of the wall of the blood vessels. ■;. Nervous, of which no satisfactory explanation can be given. Thrombosis. Definition.—The coagulation of the blood at some part of the blood vascular system, the clot remaining where it is formed. Seats.—A thrombus may form in the heart, arteries, capilla- ries or veins; it is most usually found in the veins. Causes of Thrombi.— I. Disease or loss of the endothelial lining of the vessels, from injuries whether mechanical or chemical, inflam- mation (as in endo-carditis), defective nutrition of the vascular walls. 2. Feeble circulation, which not only causes defective nutrition of the walls of the vessels, but makes the blood more liable to coagulate from stagnation. 3. Certain abnormal states of the blood itself, which cause defect- ive nutrition of the walls or in which there may be an increase of the fibrin factors. 4. The presence of foreign bodies in the vessel such as pieces of calcareous matter, cancer, &c. Varieties of Thrombi.—i. Red, usually caused by the coagu- lation of the whole mass of blood at once. 2. White, usually formed gradually by the deposit of fibrin and blood plaques in successive layers. Differences Between Thrombi and Post-Mortem Clots. Thrombi. Post-Mortem Clots. Color, dark throughout or Color, dark, with buff layer " white and laminated. of greater or less thickness on the surface. Adherent to the wall of the Not adherent to walls of the heart or vessels. heart or vessels. Later Changes in Thrombi.—i. Decolorization, from break- ing up of the red corpuscles and absorption of their coloring matter. io PRACTICE OF MEDICINE. 2. Resolution or absorption, in which the thrombus is gradually softened and absorbed, the vessel becoming pervious again. A clot of small or moderate size, good general health, and an abundance of blood vessels in the neighborhood of the thrombus are necessary for resolution to occur. 3. Organization—a frequent change—in which connective tissue gradually takes the place of the thrombus. White blood cor- puscles enter the thrombus from the wall of the vessel and small blood vessels from the same source, the corpuscles leading to the formation of the connective tissue. 4. Calcification, or the formation of a mass of chalk. Its pro- duction will be explained in connection with calcareous degenera- tion. 5. Softening, which may be (1) simple, from the gradual breaking down of the clot into a mixture of granular and fluid matter looking like pus ; (2) infective, in which the softened, broken up thrombus con- tains germs which render it infective, as in the thrombotic form of puerperal septicaemia. 6. Putrefaction due to the entrance into the clot of the germs of decomposition. Results of Thrombosis.—1. Changes in the wall of the vessel at the seat of the thrombus, due to the thrombus acting as a foreign body and setting up inflammation and causing thereby (1) cloudy swelling and desquamation of endothelium ; (2) infiltration of the walls of the vessel with serum and leu- cocytes ; (3) later on thickening and hardening of the wall from the formation of new connective tissue. 2. Obstruction to the circulation. 3. Embolism, from lodgment of a piece of the clot in some other vessel. Embolism. Definition.—The plugging of a vessel by a body, usually solid, which was circulating in the blood and lodged in a vessel too small' for it to pass through. Sources of Emboli. — 1. Ihrombi. 2. Vegetations, atheromatous, or calcareous masses from the car- diac valves. 3 Pieces of new growth, as cancer or sarcoma . . 4. Parasite*, little clumps of which sometimes gain access to the vessels in certain acute infectious diseases, as dysentery 5. /^.particles of which sometimes gain'access to the vessels especially in cases of fracture of bones. 6. Tigm^ntary matters, a rare source PRACTICE OF MEDICINE. ir J. Air, a very unusual source of emboli. Emboli found in the pulmonary artery or its branches or the pulmonary capillaries, usually come from the veins or the right side of the heart. Emboli found elsewhere in the body except in the liver usually come from the arteries or the left side of the heart. Emboli found in the liver usually come from the organs connected with the portal system of veins. Results of Infective Embolism.—1. Infective inflammation and abscess at the seat of lodgment from the action of germs and the ptomaines formed by them. Results of Simple Embolism. —1. Irritation, inflammation and softening of the wall of the vessel at the seat of lodgment, with subsequent formation of an aneurism there. 2. Local anaemia and its results. 3. Infarctions. Infarctions. Seats.—Any organ or part having terminal vessels. Shape.—Pyramidal from arrangement of the branches of the artery. Varieties.—1. White, from coagulative necrosis of tissues de- prived of blood. 2. Red, from the passage of blood from neighboring capillaries into those whose supplying artery is plugged. The red corpuscles and other elements of the blood then pass out of these vessels and collect in the tissues around. Terminations.—1. Absorption of the greater part of the exu- date and necrosed mass and formation of a cicatrix, 2. Partial liquefaction and cyst formation. 3. Calcareous degeneration. 4. Gangrene from entrance of germs of decomposition. PATHOLOGICAL RELATIONS OF BLOOD PRESSURE. Hydro-static pressure influences the venous system only and is of practical importance in connection with varicose veins of the lower extremities. Hydro-dynamic pressure or arterial tension is dependent on: 1. The volume of blood. 2. The size of the vessels ; for the amount of blood being the same the greater the capacity of the arterial system the less will be the tension. 12 PRACTICE OF MEDICINE. 3. The facility with which the arteries empty into the capillaries ; facility of discharge of blood of course lessens vascular tension in the arteries. 4. The force of the heart; it is manifest that other things being equal the blood pressure will be in direct proportion to the strength of the heart's beat. Causes of High Arterial Tension. — 1. Increased heart pmv- er from exertion, stimulants and certain diseases, as hypertrophy. 2. Increased resistance of the vascular walls from spasm of the muscular coat or atheromatous disease, or from arterio-capillary fibrosis. 3. Increased resistance accompanying cirrhotic Bright's disease. Evidences of High Tension.— 1. Incomprcssibility of the ar- teries, because an elastic tube filled with fluid is much less com- pressible than one partially filled. 2. Accentuation of the aortic second sound because the tension of the vessels forces the blood back against the aortic valves at the end of the systole and causes them to shut with unusual force, thus causing an accentuation of the second sound. 3. Prolonged first sound of the heart, because the heart cannot drive the blood as rapidly into full vessels as into those which are less full. 4. Abundant flazv of limpid urine, because the amount of water discharged by the kidneys is in direct proportion to the blood pressure. Results of High Tension.— 1. Cardiac or projcoidial pain the cause of which is not clear. 2. Atheroma of the vessels. 3. Apoplexy, in consequence of the atheromatous disease of the arterial.walls and the increased pressure of the blood in the vessels. Causes of Low Arterial Tension.—1. Diminished cardiac force brought about by (1.) direct or reflex nervous influence ; (2.) exhausting diseases or loss of blood ; (3) certain diseases of the walls of the heart; (4) certain drugs; 2. Diminished peripheral resistance due tc (1) exhausting diseases; {2.) certain drugs, as aconite and amyl nitrite • (3.) nervous influences as in shock, when the vessels of the splanchnic area are greatly dilated and the tension in the arteries correspondingly diminished. Evidences of Low Arterial Tension. — 1. A feeble and y/ first sound of the heart because in consequence of the dihtatio f PRACTICE OF MEDICINE. 13 the vessels but little blood passes into the ventricle during diastole, and as there is but little pressure in the vessels, a feeble contraction of the ventricle is sufficient to empty it. 2. A compressible pulse, because the vessel walls are not put * upon the stretch from internal pressure. 3. A scanty flow of urine for obvious reasons. 4. Pallor andfaintness because the blood is chiefly in the dilated vessels of the splanchnic area and the skin and cerebral centres are badly supplied with blood. Inflammation. Definition.—The series of changes which occur in the tissues when an irritant is applied, provided such irritant is not sufficient to cause the death of the tissues. The Changes in the Blood Vessels and Circulation are— 1. Sometimes a fleetitig contraction of the smaller vessels, which is due to the direct effect of the irritant upon the contractile mus- cular tissue or the contractile protoplasm. 2. Dilatation of the small vessels, which always occurs and may be due to one of three things— (1) paralysis of the vaso-constrictor nerves ; (2) irritation of the vaso-dilator nerves ; (3) paralysis and loss of tone of the walls of the vessels them- selves. A change in the vascular wall itself is the probable cause of dilatation of the vessels. 3. Retardation of the blood current. 4. Sticking of white corpuscles to the sides of the small veins and gradual blocking of the vessels thereby. 5. Impaction of the capillaries with red blood corpuscles, oscil- lation, stasis and thrombosis. 6. Escape of flidd and both white and red corpuscles from the vessels. All of these phenomena are due to a change in the vascular wall, which leads to stagnation and passive hyperaemia, and these cause a still further change in the vessel wall by which it becomes more permeable to fluids and also to the blood corpuscles. The white corpuscles pass out by diapedesis—a little offshoot passing through the wall first and the rest of the corpuscle follow- ing it; the white corpuscles are active and not passive agents in this process. The red blood corpuscles and fluid are forced out by pressure, but pressure would be insufficient to produce such a result unless there had been a change in the vascular wall making it more permeable. The white corpuscles pass out of the small "4 PRACTICE OF MEDICINE. veins chiefly ; the red pass out of the capillaries ; neither of them pass through the arterial walls. The Essential Lesion of Inflammation is a change in the vas- cular wall, as is shown by the following tacts : i. Inflammation will occur in a part when all the nerves going thereto have been divided. 2. The blood which was retarded while passing through an in- flamed spot will flow freely after it passes it. 3. It milk be allowed to flow through a frog's vessels, instead of blood, it will be retarded in its course at an inflamed spot just as blood would be. 4 Irritant fluids passing through the vessels will set up inflam- mation. The Changes in Inflamed Tissues are—1. Infiltration with fluid and white and red corpuscles, which has just been explained. 2. Cloudy swelling of the tissue cells, which is a degenerative change and is attended by a loss or diminution of function. It was formerly thought that there was a proliferation of the connective tissue corpuscles in inflammation, but this view has been abandoned. The Probable Functions of the White Corpuscles which pass out of the vessels in inflammation, are—I. To act as scaven- gers and to carry away waste products, such as broken up red and white corpuscles, parasites, &c. 2. To destroy parasites (bacteria) by surrounding them, each cell taking up one or more parasites, and then destroying them by a process of digestion. Such cells or leucocytes are called phago- cytes. The Ultimate Disposition of the Leucocytes which pass out of the vessels in inflammation. 1. Some of these leucocytes probably return to the circulation by the lymph channels immediately. 2. Some take up into their substance the products of the in- flammation and carry them off through the lymph channels and thence into the blood vessels, which in turn carry the effete matters to the eliminative organs. 3. Some take up bacteria into their substance and either kill the bacteria or are killed by them. If they kill the bacteria they carry them off just as they would any other effete matter- if the bacteria kill the cells they either break up and are carried off by living cells, or if pyogenic germs are present pus is formed which may be (1) absorbed, (2) evacuated by the bursting of the abscess or (3) may undergo some form of degeneration. 4. Finally, such cells may be converted into conncctrrr tissue or into giant cells. (See Nature of the Exudate.) PRACTICE OF MEDICINE. 15 Explanation of the Clinical Phenomena of Inflammation.— I. Redness is due to the dilatation of the vessels and the increased amount of blood in the tissues therefrom. 2. Heat is due to the same cause. 3. Swelling is due to the exudation from the blood vessels into the tissues. 4. Pain is due to (1) the pressure of the exudate on the terminal filaments of the sensory nerves and (2) to the irritation of such fila- ments by the leucomaines formed by the germs. 5. Fever is due to an effect produced on the heat regulating ap- paratus by (1) reflex action or (2) the absorption of leucomaines and their action on the heat centre or centres. 6..Defective nutrition is due to (1) the defective supply of pure blood to the tissues and (2) probably also to an obscure condition of the tissues themselves which renders them unfit to absorb nutri ment. Nature of the Exudate in Inflammation.—The nature of the exudate varies in different cases according to : 1. The intensity of the cause. 2. The duration of the cause. 3. The nature of the cause. 4. The resisting power and the blood supply of the tissues. The following are the different forms of exudate: 1. Serous or liquid, which occurs usually in inflammations which are mild in intensity. It contains leucocytes in small numbers. 2. Fibrinous in which the exudate soon becomes firm or " set ;" inflammations in which this form of exudate occurs are usually acute in duration and of considerable intensity. A greater or )tss number of leucocytes is found caught in the fibrinous exudate. 3. Productive in which a large number of cehs pass into the tis- sues, with little intercellular substance, and these cells may under- go one of two changes; (1) they may grow and elongate and then form connective tissue or (2) several cells may unite to form a very large cell which is branched and which is called a giant cell. On the surface of a healing wound there often appear little elevations or " granulations " each of which has in its centre a little capillary loop and around this loop a number of cells some of which are or- dinary leucocytes and some have grown, so as to loim much larger oval cells with a very distinct neucleus; such enlarged cells usually form connective tissue (a scar) and are called fibro-blasts or forma- tive cells or (epithelioid) cells. They have no connection whatever, however, with epithelium. 4. Suppurative, in which the exudate consists of a great number of cells with a liquid intercellular substance. The cells are called pus cells; they are white corpuscles which have passed out of the vessels and have died either from want of nourishment or from the the action of bacteria or their products (leucomaines). They i6 PRACTICE OF MEDICINE. differ from living leucocytes in being more granular and containing three small nuclei, as a rule. The Relation of Bacteria to Pus Formation.—The presence of certain bacteria is necessary to pus formation ; the most impor- tant of these bacteria are (i) the staphylococcus pyogenes aureus, (2) the slaphylococcus pyogenes albus, (3) the streptococcus pyo- genes. These bacteria seem to have the power of killing many leucocytes and also of peptonizing and liquefying the exudate, which would otherwise be fibrinous. 6. Hemorrhagic, in which great numbers ol red corpuscles pass out of the vessels as well as white. This can only occur when the nutrition of the vascular walls is very serious'y impaired, and hence only occurs in cases where the inflammation is severe in intensity. The Causes of Inflammation.—A. The predisposing cause, which is often, but not necessarily, present, is defective nutrition ol the tissues which may be 1 Constitutional, or 2. Local. Constitutional defects in the strength and vigor of the tissues may be (1) hereditary, as in scrofula and phthisis ; or (2) acquired, as in alcoholism, diabetes, Blight's disease, &c. Local defects in the nutrition of a part are due usually either to injury or local anaemia ; some defect of development may cause it. B. The exciting causes of inflammation may be— I. Traumatic. 2. Trophic. (?) 3. Bacterial or infective. 1. The trauma or injury in the traumatic form of inflammation maybe produced by(i) mechanical, or (2) chemical violence or (3) by the action of heat or cold. The Characteristics of Inflammation Due to a Trauma are— (1) it shows no tendency to spread ; (2) it has no tendency to continue when the cause is removed. 2. The trophic disturbances of nutrition are due to nervous in- fluence. The affection of the nerve leading to such an inflamma- tion may be situated either in the nerve centers or in the nerve fibres. It is not cxrtain that trophic disturbances are exciting causes of inflammation ; they may merely interfere with the nutrition of a Part and hence render it more liable to inflammation when an exciting cause arises. ° 3. Ihuttria, tungi or germs are by far the commonest causes of inflammation. They may act either (1) directly upon the tissues, or PRACTICE OF MEDICINE. 17 (2) indirectly by the formation of leucomaines. The Characteristics of Inflammation due to Bacteria are— 1. It is apt to spread. 2. It is usually more tedious than an inflammation due to trau- ma. The modes in which such an inflammation may spread are— 1. By continuity or contiguity of tissue, as in simple abscess. 2. By the lymphatics, as in lymphadenitis from an infected wound. 3. By the blood 1'essels, as in the formation of "meta-static" ab- scesses from septic emboli. The Circumstances Which Influence the Action of Germs in Producing Intlammation are— 1. Arrest of the bacteria, as in septic emboli and lymphadenitis. 2. Predisposition on the part of the tissues. 3. The seat of inoculation and the anatomical arrangement of a part. 4. The blood state, such as that of diabetes in which abscesses and carbuncles are very apt to occur. 5. The species of germ ; for instance, streptococcus pyogenes is as- sociated with diffused suppuration and the staphylococcus pyogenes aureus with localized suppuration. 6. The number of germs introduced at a time. 7. The virulence of the germs or the leucomaines generated' by them ; virulence is lessened by various circumstances. 8. The presence of other species of germs; some increasing the virulence of each other and some being mutually antagonistic. 9. Probably the season of the year or atmospheric conditions. The Modes of Arrest of Inflammation.— 1. When the in- flammation is traumatic in origin it ceases so soon as the trauma is removed and the exudate is in part removed by the white blood cells and in part becomes organized. 2. When the inflammation is bacterial in origin leucocytes pass out of the vessels so as to form a wall around the seat of the bac- teria and there seems to be a sort of battle between the two (leu- cocytes and bacteria). Some of the leucocytes are destroyed by the leucomaines gene- rated by the bacteria. The bacteria are destroyed by (1) the leucocytes enveloping and digesting them, and (2) by the leucomaines which they have them- selves generated. The Varieties of Inflammation with Respect to the Gene- ral symptoms are—1. Sthenic, which is characterized by a full, strong pulse, flushed face, and usually by excitement. 18 PRACTICE OF MEDICINE. 2. Asthenic, characterized by exhaustion. 3. Typhoidal, in which there is not only great prostration, but a dry, brown tongue, sordes on the teeth, low muttering delirium and diarrhoea. The Varieties of Inflammation Classified with Reference to the part involved and the character and nature of the exudate are—1. CatarrJial, in which the mucous membranes are affected. The exudate is serous in character, but contains large quantities of mucous and great numbers of epithelial cells which have desquam- ated and undergone fatty degeneration ; there is also a consider- able number of leucocytes. 2. Croupous and diplitheritic, in which mucous membranes are affected and the exudate is fibrinous in character. A croupous membrane is chiefly on the surface of the mucous membrane and consists of fibrin, leucocytes and superficial flakes of mucous mem- brane which have undergone coagulative necrosis. A diphtJieritic membrane affects the mucous membrane more deeply and seriously than a croupous one ; it consists of fibrin, leucocytes, thick masses of mucous membrane which have undergone coagu- lation necrosis, and also great numbers of micrococci. 3. A parenchymatous inflammation is one in which the essential cells of an organ are chiefly involved. 4. hi interstitial inflammation the connective tissue frame work of an organ is chiefly affected. Acute and Chronic Inflammation.—1. Acute inflammation runs a rapid course; it may be mild or severe in intensity. The exudate may be serous, fibrinous, purulent or hemorrhagic. The vessels have lost the power to contract. 2. Chronic inflammation runs a slow course, and is usually com- paratively mild in intensity. The exudate may be serous, fibrinous, purulent, or productive. The blood vessels have the power to contract, but must be stimu- lated to do so. Terminations of Inflammation.—1. Resolution, in which the exudate is absorbed and the tissues return to their normal condi- tion; the requisite conditions are (1) removal of the cause (A re turn of the vessel wall to a healthy condition, (3) absorption of the exudate. 2. Organization, in which connective tissue is formed from the leucocytes. LUC 3. S-ftcning and discharge (abscess formation) 4. Certain degenerations, such as fatty and calcareous 5. Necrosis or death of the tissue from either (1) the dire^ tion of the irritant upon the tissues, or (2) the pressure of th ^ date on the blood vessel and the consequent cutting off of blood"" PRACTICE OF MEDICINE. 19 Regeneration and Repair of—1. Nervous, muscular, glandu- lar, and epithelial tissues. Nerve ganglion cells are never regenerated. Nerve fibres and muscular fibres may be regenerated by growth and division of their nuclei. Glandular and epithelial tissues can only be regenerated by the multiplication of cells of the same character as the tissue itself. None of these tissues are regenerated from leucocytes. 2. Connective tissue is rgenerated by (1) the conversion of leuco- cytes into connective tissue fibres or cells, and (2) the multiplication of connective tissue corpuseles. The Conditions Favorable for Regeneration and Repair are: 1. The removal of the cause. 2. An abundant supply of pure blood, and 3. In the case of nervous and muscular fibres and glandular and epithelial tissues the presence of such tissue at the inflamed spot. The Treatment of Inflammation.—The indications are— 1. To lessen the amount of blood in the inflamed part. 2. To relieve pain. 3. To lessen or relieve fever. 4. To promote resolution. 5. To destroy bacteria, or prevent the effects usually produced by them. 1. To lessen the amount of blood in the inflamed area in acute cases. (1) blood-letting, general or local, has been used ; it is of com- paratively little value; (2) Agents which dilate the vessels of the skin, and thus produce a collateral anaemia of internal organs, are extremely useful. Such agents are poultices and diaphoretics, and also' nauseants, aconite and veratrum. To lessen the amount of blood in an inflamed part in chronic cases, agents are indicated which will stimulate the walls of the ves- sels to contract, such as (1) counter-irritants ; (2) ergot; (3) electricity ; (4) massage ; (15) astringents ; 2. To relieve pain : (1) opium and other analgesics, such as phenacetine, antipyrine, acetanilide, exalgine, &c; (2) heat, which relaxes the tissues and relieves tension ; (3) cold, which lessens the power of sensory fibres to convey painful impressions; 20 PRACTICE OF MEDICINE. (4) local blood-letting, which relieves the tension in the tissues (pressure) directly. 3. To lessen or relieve fever—see " Fever." 4. To promote resolution, suitable nourishment and tonics are indicated in order to furnish proper blood for the repair of the vascular walls and other tissues. 5. To destroy bacteria and prevent their effects, antiseptic treat- ment is to be employed, as the use of antiseptic sprays, as in diph- theria. Fever. Animal Heat is due to oxidation of food usually, but probably of the tissues also, in disease. The oxidation takes place in the muscles and glands, especially the former. Influence of the Nervous System on the Production of Heat. There are two sets of nervous influences which regulate the pro- duction of heat—(1) thermogenic, or heat forming, and (2) thermo- inhibitory, which check heat formation. Thermogenic centres exist apparently both in the brain and spinal cord. Thermo-inhibitory centres exist in the brain only. The regulation of the body heat is called thermo taxis. About 80 per cent, of the heat loss ocurs from the skin by (1) radiation of heat; (2) evaporation of sweat. The greater the amount of blood in the skin the greater will be the heat loss, and the amount of blood in the skin is regulated by (1) the size (dilatation) of the vessels and (2) the force and fre- quency of the heart's action. About 20 per cent, of the heat loss occurs from the lungs, the heat being expended in warming the inspired air. So that the more rapid the respirations the greater will be the heat loss. The Normal Temperature of the Human Body is: 1. In the axilla from 98°-99°. 2. In the mouth from 98.5°-995°. 3. In the rectum from 99°-ioo°. There is a diurnal variation in health, the temperature being about three-fourths of a degree higher in the afternoon from 4 to 6 than it is in the early morning hours from 2 to 4. The tempera- ture of the body remains practically constant in winter and sum- mer, and is regulated in the following manner: 1. Heat, whether from without or as a result of internal com- bustion (violent exercise, &c.,) causes : t PRACTICE OF MEDICINE. 21 (i) dilatation of the vessels of the skin and loss of heat by radiation. (2) sweating and loss of heat by evaporation; (3) more rapid breathing and consequent increased loss of heat in warming the inspired air. 2. Cold causes: (1) contraction of vessels and less radiation ; (2) dryness of the skin and less evaporation, and also less ra- diation because a moist skin is a better conductor than a dry one ; (3) slozver respiration, so that less air is taken in inspiration and less heat is consequently expended. The Nature Of Fever.—Fever is caused by excessive heat for- mation and not by diminished heat loss; this is proved by the fol- lowing facts : 1. The amount of C02 and urea is increased in fever. 2. If a fever patient and a well person are placed in water of the same temperature, the fever patient will heat the water more than the well person. The Phenomena of Fever and Their Explanation.—i. Dis- turbances of temperature. (1) the temperature is elevated: ioi°. Fahr. is a slight fever; 102.5 a moderate fever and a temperature over 1030. a high fever; a temperature of 1060. is very serious, and recovery is rare if the temperature reaches no0; (2) the diurnal variation is usually observed as in health; (3) the temperature is more easily affected in fever than in health ; some antipyritics will reduce the temperature in fever and not in health. The disturbances of temperature are due probably to some de- fect in the action of the thermogenic or thermo-inhibitory heat centres, and this defect may be caused by : (1) the action 0*1 the centres of certain morbid products (leuco- maines) circulating in the blood as in scarlet fever, for instance; (2) reflex action as in the so-called "urethral fever", observed sometimes after passing a bougie ; (3) some functional disturbance of these centres as in certain cases of hysteria with high temperature; (4) some injury of the heat centre or conducting fibres. 2. Disturbances of the circulatory system : (1) the pulse is more rapid because the heart is stimulated by warm blood. In the late stages of fever the pulse becomes weak in consequence of albuminoid degeneration of the muscular tissue of the heart (from leucomaines); (2) the red corpuscles are diminished in number, because the food is burnt off and the normal formation of corpuscles is pre- vented. 22 PRACTICE OF MEDICINE. 3. Disturbances of the respiratory system : (1) the respirations are more frequent because the over-heated blood stimulates the respiratory centre, and possibly leucomaines have the same effect; (2) more C02 is discharged because of increased combustion. 4. Disturbances of the nervous system, excitement, delirium, stupor, &c, due to the action of over-heated blood and leucomaines, 5. Disturbances of the muscular system, such as weakness and twitching of the muscles from (1) degenerative changes due to leucomaines. (2) actual consumption of muscular tissue. 6. Disturbances of the digestive system, such as loss of appetite, nausea, constipation, &c, due to (1) albumoid degeneration of secretory and absorbant cells caused by leucomaines; (2) degenerative changes in the muscular coat of the bowels produced in the same way. 7. Disturbances of the excretory organs (kidneys, &c.) (1) less water discharged than in health, because the blood pressure is lessened ; (2) more urea and uric acid are discharged in consequence of increased oxidation ; (3) sometimes albuminiria occurs from the degenerative changes in the cells of the urinary tubules, such changes being caused by leucomaines. 8. Disturbances of nutrition (emaciation and debility) in conse- quence of (1) improper quality of the blood ; (2) impaired action of the digestive and absorbent glands; (3) direct destruction of tissue by oxidation, in the febrile pro- cess. The Modes of Termination of Fever are—1. Crisis, when the temperature falls suddenly. 2. Lysis, when there is a gradual fall of temperature. The Varieties of Fever classified according to the course of progress of the symptoms, especially the elevation of temperature, are—1. Continued, when the temperature remains elevated with only a slight diurnal variation. 2. Remittent, when the temperature undergoes marked remis- sions. 3. Intermittent, when the patient is at times free from fever • in such cases the fever usually recurs periodically. 4. Relapsing, in which there is apparent recovery and then a relapse. Classification According to the Severity and combination of PRACTICE OF MEDICINE. 23 the symptoms.— 1. Simple, in which the rise of temperature is not accompanied by any other serious disturbances. 2. Hectic or suppurative, which is caused by the absorption of leucomaines generated in suppuration. 3. Adynamic, in which there is great depression of the vital powers. 4. Typlwidal, in which there is prostration, dry and brown tongue, low muttering delirium, sordes on the teeth and usually diarrhoea 5. Malignant, in which a large quantity of poisonous leuco- maines is suddenly thrown into the system and overwhelms the patient. The Causes of fever have already been stated under the head of " Disturbances of Temperature." The Prognosis of Fever is Dependent on—1. Its intensity and duration. 2 Its type, whether simple, typhoidal, &c. 3. The previous health of the patient, a person in impaired health succumbing more readily to a febrile attack. 4. The existence of complications, which nearly always render the prognosis worse. The Treatment of Fever.—The indications are— 1. To lessen heat production. 2. To increase heat loss. The agents which lessen heat production are— (1) antipyrine ; (2) acetanilidt ; (3) phenacetine ; (4) salicylic acid and its salts ; (5) alcohol, to a slight extent. The agents which increase heat loss are— 1. Such as increase the dilatation of the vessels of the skin, and -> Increase the amount of szvcat. The same drugs for the most part act in both ways; these drugs are— (1) aconite ; (2) veratrum ; (3) sweet spirits of nitre; (4) acetate of ammonia, &c; (5) opium, especially Dover's powder. 3. Agents which withdraw heat directly, such as (1) the cold bath; (2) cold sponging ; (3) the wet pack. Diet in Fever.—The diet in fever cases should be easily digest- -4 PRACTICE OF MEDICINE. ed and assimilated, because of the condition of the digestive glands, and nutritious, because of the waste which fever causes. Atropiiv. Definition.—A wasting or diminution in size of a part or organ. The Varieties of Atrophy are—i. General, when the whole body is involved. 2. Local, when the atrophic change is localized. • The Changes in an Atrophied Organ, as a rule, are—i. Di- minution in the size or number (or both) of its essential elements (such as cells or nerve or muscular fibres), and 2. An increase in the connective tissue frame work. The Causes of (A) General Atrophy a e— i. Defective nourish- ment as in cases of cancer ot stomach or atrophy of the gastric tu- bules. 2. Excessive waste, as in consumption and profuse suppuration ; nd also in chronic diarrhoea. 3 Impaired vitality, as in old age when the cells are incapable of apprc J riating nourishment in pr >per quantity. The Causes of (B) Local Atrophy, are—i. Defective supply of blood to a part from narrowing of a vessel, or a partial cutting off of the blood supply. 2. Diminished functional activity, as the atrophy of muscles which occurs trom pro onged disuse. 3. Defective nervous influence (trophoneuroses), as in infantile paralysis (or acute anterior polio-myelitis.) Hypertrophy. Definition.—An increase in the size of a part or organ. The Varieties of Hypertrophy are—1. Simple when there is an increase in the size 01 the cols of which a tissue is composed without any increase in number, and 2. Hyperplasia when there is an increase in the number of the cells. As a rule, the cells are increased both in size and number. The Causes of Hypertrophy are-i. An increased blood sup- fly, as in acne rosacea. r 2. Incensed functional activity which is the cause of the enor mous development (hypertrophy) of certain muscles Irom use such a-> hypertrophy of the heart. C,SUU1 the enlargement of :i„ organ or part which occurs as a rcsu't practice of medicine. 2^ of inflammation is not a true hypertrophy, because the enlargement is due to the formation of connective tissue. The Degenerations. Definition.—By the degeneration of a tissue or organ is meant such a change in its quality that it is rendered less capable of per- forming its functions. Parenchymatous Degeneration. Definition.—A change in the tissues, usual'y the parenchyma, of an organ by which albuminous granules appear in its cells. Synonyms.--Albuminoiddegeneration; granular degeneration; cloudy swelling. Nature and Appearance.—Tissues in which such a degenera- tive change has occurred contain granular, albuminous particles which are soluble in acetic acid. The tissue,cells are opaque and swollen. The Seats of cloudy swelling are—I. The cells of muscular tissue, such as that of the heart, &c. 2. The cells of glandular organs, as the liver and kidneys. 3. Connective tissue cells, as in inflammation of the cornea. The Causes of cloudy swelling are—1. Possibly a prolonged high temperature. 2. The action of leucomaines. 3. Certain poisons, such as arsenic and phosphorus. Cloudy swelling is always a step towards death of the tissue. The Results of Albuminoid Degeneration are—1. Impaired function. 2. Usually a return to the normal state, but 3. It may result in fatty degeneration. Mucoid and Colloid Degeneration. Definition, Nature and Appearance.—1. In mucoid degene- ration a substance is formed resembling mucous in appearance. 2. In colloid degeneration a jelly-like mass is formed. Colloid matter differs from mucoid furthermore in containing sulphur, and not responding to the tests for mucine. The Seats of (A) Mucoid degeneration are— 1. The epithelial cells lining the mucous membranes in catarrhal inflammations. 2. Certain new formations, such as the myxo-sarcomata, occa- sionally the connective tissue, as in myxoedema. 26 PRACTICE of medicine. The Seats of (B) Colloid degeneration are—1. Certain tumors, especially malignant growths of the ovaries. 2. Occasionally cartilage. The causes of mucoid and colloid degeneration are unknown. The results are loss of function, and the tissues affected never return to their normal state. Fatty Degeneration. The Varieties of Fatty Degeneration are—i. Fatty infiltra- tion, when the fat is deposited between the fibres of muscles or in a gland without destruction of its protoplasm, and 2. Fatty metamorphosis when the fat takes the place of the pro- toplasm of the cell or muscle fibre. In the case of glands, such as the liver, it is sometimes difficult to distinguish fatty infiltration from fatty metamorphosis. The Nature and Appearance of tissues which have under gone fatty degeneration. They are—i. Pale, because the blood vessels are compressed. 2. Yellenvish, from the presence of fat. 3. Softened, for the same reason. The Chief Seat of Fatty Infiltraton is in the connective tissue; and it is of serious moment when situated in the connective tissue, between the muscular fibres of the heart; it is common also in the liver cells. The Chief Seats of Fatty Metamorphosis are—1. Muscu- lar tissue, as in certain cardiac troubles. 2. The cells of glandular organs, as in certain cases of Bright's disease. 3. The exudation of inflammation, especially when rich in cells. 4. The coats of the small arteries. The Causes of fatty degeneration are—1. The excessive use offatty food, or food from which fat is formed. 2. A sedentary and indoor life. 3. Defective oxidation from either general or local anaemia 4. Alcohol which probably interferes with oxidation or else is purnt off in place of fat in heat formation. 5. Certain protoplasm poisons, such as phosphorus 6. Lozucred vitality from any cause, such as old age, &c. fected. The Results of fatty degeneration depend upon the organ af- The Termination is cheesy degeneration from the drying up and crumbling of the cells which have undergone fatty d£enera tion, and this caseous mass may undergo either "genera- practice of medicine. 27 I. Softening,, if so situated that fluid can get access to it, thus forming a milky-looking fluid (pathological milk) or 2. Calcareous degeneration, q. v. Cheesy or caseous degeneration, as it is sometimes called, is es pecially apt to occur in lymphatic glands, and such masses may re- main there for sometime before undergoing softening or calcifica- tion. Calcareous Degeneration. Definition.—A deposit of calcareous matter in certain tissues or parts. Synonym.—Calcification, ossification (of the heart or arteries). The Nature and Appearance of a part in calcareous degen- eration. There is a deposit of lime-salts which renders the part hard, brittle, and granular. Rarely there is actual formation of bone. The Usual Seats of calcareous degeneration are—1. Inflam- matory exudates, as in some cases of peri-carditis and of pulmonary phthisis. 2. Tumors, such as uterine fibroids. 3. The coats of arteries, as in atheroma or calcification; these changes in the arteries frequently lead to thrombosis and embolism and to attacks of angina pectoris. The Causes of calcification are—1. Previous disease of the tis- sues by which their vitality is depressed. '2. Old age, which probably causes a depression of the vitality of the tissues. 3. Fatty degeneration. The immediate or actual cause of calcification is not known. The above are only predisposing causes. The Results and Terminations depend on the organs or tis- sues involved. Amyloid or Waxy Degeneration. Nature and Appearance. Tissues which have undergone this degeneration have a waxy appearance, the cells become translucent and merge into each other so that their outlines are lost; the organ is firm and brittle at the degenerated point. If tincture of iodine be poured over the seat ot waxy degeneration it will produce a ma- hogany color. The nature of the degeneration is unknown. 28 PRACTICE OF MEDICINE. The Usual Seats of the degeneration are—1. The spleen. 2. The liver. 3. The kidneys. 4. The bowels. 5. The muscles. The change begins in the wall of the blood vessels. The Causes of waxy degeneration are—1. Prolonged suppura- tion, especially from disease of the bones. 2. Syphilis. 3. Possibly cancer, gout, &c. The Result is permanent loss of function. The Termination is never in recovery so far as known and sooner or later such cases end in death. Fibroid Degeneration. Definition.—A change in an organ or part, consisting in an atrophy of its parenchyma and an increase in its connective tissue frame work. Synonyms—Fibroid substitution. Nature and Appearance.—In fibroid degeneration the organ or part is usually smaller and harder than normal. The change may occur in three ways: 1. There maybe first atrophy of the parenchyma, and then an increase of connective tis- sue in consequence. 2. The increase of connective tissue maybe the primary change and may cause atrophy by pressure on the parenchymatous cells and their nutrient vessels. 3. The two processes may be simultaneous and due to the same cause. As a general rule, fibroid degeneration is the result of chronic (productive) inflammation, but it is possible in certain cases (sys- temic cerebral and spinal lesions) that it is not inflammatory. The Usual Seats are—1. The liver (in cirrhosis). 2. The kidney (in the sclerotic form of Bright's disease). 3. The blood vessels (in arterio-capillary fibrosis). 4. The nerve centres (in systemic lesions). The Causes differ in different cases, and will be studied in con- nection with individual diseases. The Results depend on the seat. The Termination is in permanent loss of function. practice of medicine; 29 TUBERCLE AND TUBERCULOSIS. Definition.—By tubercle is meant a small enlargement, inflam- matory in character, consisting usually of one or more giant cells, surrounded by epithelioid cells and leucocytes, and having a reticu- lum or stroma of homogeneous or fibrillated tissue. Tubercles are due to inflammatory action, set up by the " bacillus tuberculo- sis ;" and the infectious disease " tuberculosis" is due to the tubercle baccilli. Varieties of Tubercle.—1. Grey, when fresh, and fatty degen- eration of the cells has not occurred. 2. Yellow, formed from the grey by fatty degeneration and case- ation of the cells. Size of Tubercle.—A single tubercle is about -^ of an inch in diameter, but a number may be united to form a mass as large as a hazel nut, or much larger. Seats of Tubercle.—1. Respiratory organs or tracts. 2. Serous membranes, such as the pleura, peritoneum, cerebral meninges, joints, &c. 3. Mucous membranes of bowels, &c. 4. Lymph glands, kidneys, spleen, testicles, bowels, skin, &c. When Most Liable to Occur.—Tubercle is most liable to oc- cur in childhood or early adult life, but no age is exempt. Histological Structure.—A tubercle is usually formed of the following parts—1. One or more giant cells in the centre. 2. A number of epithelioid cells around these giant cells. 3. A still larger number of leucocytes around the epithelioid cells. 4. A delicate reticulum or stroma which may be homogeneous or fibrillated. No new bloodvessels are ever found in tubercle. In cases of acute tuberculosis lymphoid cells (or leucocytes) predominate, and may be the only ones present. Origin of Cells in Tubercles.—Tubercle is an inflammatory formation, and the cells in it are derived from—1. White blood cells. 2. Possibly from epithelium, but this is extremely doubtful. Secondary Changes in Tubercle.—The secondary changes are—i. Caseation, which is by far the most common, and 2. Fibroid change—the formation of connective tissue. Caseation occurs especially in the glands, but it often occurs in other places ; the caseous change commences in the centre of the tuberculous mass. Fibroid change occurs on serous membranes and in chronic 3b practice of medicine. cases of pulmonary tuberculosis. Frequently fibroid change oc- curs around a caseous mass, and thus serves as a protecting wall. The Further Changes after Caseation are— i. Encapsulation' when the outer layer of leucocytes becomes converted into connec- tive tissue and forms a wall around the caseous mass. 2. Calcification, from a deposit of lime salts in the caseous form- ation. This occurs most frequently in the mesenteric glands, but is not uncommon in the lungs and other organs. 3. Softening, and the formation of cavities in the lungs or of cold abscesses in connection with caseous bones, &c. The Terminations of Tuberculosis.—1. The tuberculous matter may be discharged or removed artificially, and the resulting wound may heal by scar tissue. 3. "Obsolescence" may be induced by (1) the formation of a wall of connective tissue around the tubercle, or (2) the calcification of the caseous mass. 4. Death may be caused in a number of ways— (0 by poisoning, as in acute tuberculosis ; (2) by exhaustion, the usual mode, &c, &c. As long as a caseous mass of tubercle remains in the body of a pa- tient, even though it may be surrounded by connective tissue, such per- son is in constant danger of sudden and fatal extension of the tuber- cular disease. Causes of Tuberculosis.—The essential cause is the Bacillus Tuberculosis. The Characteristics of the bacillus tuberculosis are as follows: It is a single celled plant, rod shaped ; about y^^- or -gJ^ of an inch in length, and about one-sixth as broad as it is long. It has rounded ends and shows usually clear spots in its body. It is mo- tionless. It probably forms spores. The Conditions requisite for its development and growth are— 1. It must be in an animal body ; either that of a human being or of some lower animal. It may live in the dry state outside of the body for several weeks or months, possibly, but is incapable of growth and development. 2. A temperature between 820 and 108° F. is necessary for its growth; but it flourishes best between 980 and 1020 ; it is quite resistant to both cold and heat; but prolonged cold or heat will destroy the bacilli; the spores have greater resisting powers than the bacilli. 3. A certain predisposition on the part of the person is neces- sary for the occurrence of tuberculosis. In what this predisposi- tion consists is not known. practice of medicine. 31 The Avenues by which the bacilli gain access to the body are—1. The respiratory passages ; the dry bacilli constantly float in the air and are taken in in inspiration. 2. The digestive organs ; the bacilli may be taken in with milk from tuberculous cows, or with the flesh of tuberculous animals, or flesh which has become infected secondarily (by flies, &c.) 3. By the skin, as in lupus and certain cases of chronic eczema, with consecutive disease of the lymphatic glands. 4. By inoculation, as in wounds ; this is rare in the human sub- ject. The Action of the Bacilli in the Tissues.—The bacilli or the leucomaines generated by them act as irritants and cause inflam- mation just as any other irritant does, but their action is peculiar in two respects: (1) the mass of cells formed contains no blood vessel, and (2) caseation is very apt to occur. The Modes in which Tubercle Spreads.— 1. By continuity and contiguity of tissue, as in the lungs and bronchial tubes and in the pleuia, &c. 2. bypassing along the bronchial tubes, bowels, urinary pas- sages, &c, from one point to another. 3. By lymphatics. This is a very common mode by which the disease spreads ; a few germs only may get into the blood vessels in this way, or a softened gland may burst and pour a large num- ber of bacilli into the thoracic duct and blood-current at once, thus leading to acute tuberculosis. 4. By the veins and arteries. The walls of both these sets of vessels may be perforated by tuberculous masses and bacilli may thus gain access to the circulation. The Results of exten-ion are the occurrence of tubercle in other parts of the body. If the number of bacilli suddenly thrown into the circulation is very large, acute tuberculosis will result from the involvement of many organs, and the quantity of poison (leuco- maines) generated. The Prognosis of chronic tuberculosis depends on many con- ditions, such as—1. The previous health and vigour of the patient. 2. The organ or organs involved. 3. The number of bacilli which gain access to the body. 4. The surroundings of the patient, with respect to dirt, &c. The Treatment of Tuberculosis depends upon the organ involved in great measure. The chief indications are—1. To re- move a;l caseous glands, &c. 2. To sustain the health and strength. Koch's treatment is now (January 21st, 1891,) on trial, but as yet the results have not been satisfactory. His method consists in injecting into tuberculous patients a "lymph" composed of a gly- cerine extract of the bacilli tuberculosis. 32 practice of medicine. Acute Tuberculosis. Definition.—An acute infectious disease due to the action of the bacillus tuberculosis. Causes.— I. The sudden discharge of the contents of a caseous gland into the circulation. 2. Possibly the opening of a caseous tubercular mass in some organ into a blood vessel. Often no cause can be discovered. Morbid Anatomy.— I. Miliary tubercles in many organs ot the body—the brain and the lungs are ot especial moment, because they may cause special symptoms. 2. Old tubercular products (caseous or fibrous) are olten found in some parts of the body. Symptoms.—A. In the generalized form much like typhoid fever. I. Temperature elevated from ioo to 1050 from absorption of leucomaines. 2. Respiration is usually hurried and there is cough from bron- chitis. 3. Pulse is rapid and weak from fever and exhaustion. 4. Nervous symptoms : delirium, stupor, &c, are due to leuco- inaine poisoning. 5. Digestive symptoms: Anorexia or vomiting sometimes occurs from the presence of leucomaines in the circulating blood ; consti- pation sometimes occurs from muscular weakness, but diarrhoea is more common from accompanying intestinal tuberculosis. 6. General. Emaciation and exhaustion are marked in conse- quence of the fever. B. In the cerebral form the meninges are chiefly involved. (See Basilar Meningitis.) C. Occasionally the lungs are extensively diseased with corre- sponding symptorm. (See Pulmonary Phthisis.) Physical Signs.—The physical signs depend upon the extent of the trouble in the different forms; in the generalized form they are very slight. Diagnosis.—Distinguished from typh^d fever by the absence of rose spots, the rapid respiration, the absence of tympanites and sometimes by the presence of truckling in the lungs. Prognosis.-Extremely unfavorable; duration from a few days to e ght or ten weeks. Treatment. —1. To sustxin strength by nutritious food and stim- ulants. 2 To relieve symptoms, such as diarrhaa, sleeplessness d^lirU urn, &c, by appropriate remedies. PRACTICE OF MEDICINE. 33 THE VEGETABLE PARASITES. Classification.—All the vegetable parasites of pathological interest are thallophytes, or plants in which there is no distinction be- tween the stem and the leaf. Furthermore they are devoid of chlorophyl or coloring matter, and hence are fungi and not algae. Pathological Fungi.—The pathological fungi are of three kinds—i. Bacteria or Shizomycctes or fission fungi. 2. Yeasts or Blastomycetcs. 3. Moulds or Hyphomycetes. Of these the fission fungi or bacteria are by far the most impor- tant. Bacteria, or Fission Fungi. Characteristics.—1. Bacteria are uni-cellular, non-nucleated, usually colorless plants, exceedingly minute. 2. Composition. They consist of a substance called myco-pro- tein and probably have a wall of cellulose. 3. Form. In form they may be either (1) rod-shaped {bacilli), or (2) round (micro-cocci.) Bacilli may be straight, curved or spiral. 4. Motion. The round are motionless (except for Brownian movement), the bacilli are often motile. 5. Multiplication may occur in two ways, (1) by division, (2) by spore formation. (1) In division the cells may divide and separate from each other, or the new cells may remain united. In the case of bacilli a number may be united end to end in this way, as in leptothrix. In the case of micrococci if two are united a diplococcus is formed; if a number are united end to end it is called a strepto- coccus, or chain coccus: if a number are united irregularly it is called a staphylococcus; if the cells are united in such a way as to form a cube looking like a bale of hay or cotton the collection is called sarcina; finally, if a number of cells are held together by a mass of gelatinous intercellular substance, such a mass is called zo- oglcea. The time occupied in fission is from ten to thirty "minutes. (2) Spore formation may occur in two ways, known, respective- ly as endosporous and arthrosporous. In the formation of endospores from one to three spots appear in the fungus, and the these spots grow and become round or oval in shape; finally the cell wall gives way, and the spores which have developed at the expense of the myco-protein are liberated. In the formation of arthrosfores one fungus in a chain, or cluster becomes larger than the rest and finally 34- PRACTICE OF MEDICINE. all but this one dies, while it becomes capable of growth to form a new cell. Most bacteria are probably monomorphic, that is, they do not change their form ; some are polymorphic. Conditions of Life and Growth.— I. Food. The bacteria re- quire nitiogenous food; many develop with especial facility in decomposing animal matter. Acid fluids are usually unfavorable to their development; alka- line are usually favorable. 2. Water is essential for the growth and development of all germs, but many of those which are pathogenic may exist in the dry state—for example, the bacillus tuberculosis. The endosporous germs resist drying better than others. 3. Oxygen is essential to the life of some germs and prejudicial to others. 4. Temperature is of great importance in connection with path- ogenic germs ; most of them grow and thrive best at a temperature between 980 and 1060 Fahr. Many of the fungi are killed by freezing, and boiling is still more effectual; but the spores are very resistent to both heat and cold; they may be frozen up for three months and still live, and prolonged boiling is necessary to destroy them. 5. A state of rest is favorablt for the development of nearly all the pathogenic fungi. Distribution of Bacteria in Nature.—Spontaneous generation is impossible. 1. Earth. Germs are found in great abundance in the surface soil; they disappear, however, about three feet below the surface (Koch). 2. The bodies of animals always have germs adhering to them and disease (scarlet fever, measles, &c.) may be spread in this way! 3. Clothing is always contaminated with germs. 4. Air. Germs are invariably present in the atmosphere except in mid-ocean or in deserts. The number of germs in the atmos- phere is in direct proportion to population. 5- Water. Artesian well water usually contains no germs • wa- ter from all other sources does ; the water of shallow or "surface" wells is usually rich in germs and dangerous in proportion The human body Germs occur on the surface of the body in the bronchi and in the intestinal canal of healthy persons A few may pr,ss ,nto the tissues, but in health they are readily destroyed by tne tissues themselves or the leucocytes "iroyeu Non-pathogenic germs, often called saprophytes, cannot invade and multiply in the living tissues; they can only eed upon dead substances; they are constantly present in the intestines ? Pathogenic^germs may invade and multiply in the living tissues Some seem to be able to act upon perfectly healthy tissues^, Xrs PRACTICE OF MEDICINE. 35 can only act when the vitality of the tissues is already impaired ; for example, diphtheria attacks an inflamed spot more readily than a sound one. Conditions Influencing the Action of Pathogenic Germs. These have already been considered under Inflammation (q. v.) and will only be named here—I. Predisposition, which may be gen- eral or local. 2. Arrest of the organisms. 3. The number of organisms. 4. The species of organisms. ' 5. The virulence of the organisms. 6. Concurrent grozvtli of different species. 7. Local and seasonal conditions. Effects Produced by Fungi.—1. General poisoning by the pro- ducts of germ action (leucomaines or ptomaines). 2. Local irritation or inflammation may result from the direct action of the germs or from the action of the alkaloids formed by them. 3. Embolism may occur and lead to secondary troubles, such as pyaemia and multiple abscesses. Avenues of Introduction of Pathogenic Bacteria.—1. The respiratory passages, the germs being taken in with the inspired air. 2. The digestive canal with food, water, milk, &c. 3. The genital passages, as in cases of gonorrhoeal salpingitis or gonorrhceal cystitis. 4. The skin, as in ecthyma and impetigo. 5. Inoculation, as in vaccination and syphilis. Modes in Which Pathogenic Bacteria Spread.—1. By con- tinuity and contiguity of tissue, as in the case of the bacilli of tuber- culosis, and the gonococcus. 2. By the lymphatics, as in case of syphilis, diphtheria, septi- caemia, &c. 3. By the blood vessels, as in cases of septicaemia, &c. 36 PRACTICE OF MEDICINE. CHAPTER II. THE ACUTE INFECTIOUS DISEASES. Definition.—A class of diseases which run a rapid or acute course, each of which is due to an infective agent capable of indef- inite multiplication. Members of the Class.—Typhoid fever, typhus fever, small- pox, scarlet fever, diphtheria, dengue, &c, &c Characteristics Common to the Different Members of the Class with respect to—I. Morbid anatomy. (i) Splenic enlargement; (2) albuminoid degeneration of kidneys, liver, &c.; (3) liability to inflammation of serous membranes. 2. Causes—(1) germ capable of indefinite multiplication; (2) infectiveness. 3. Clinical history—(1) incubation; (2) self-limitation; (3) immunity conferred by one attack against subsequent at- tacks of the same disease (as a rule). Classification.—1. Contagious, in which the germ is conveyed directly or indirectly from one human body to another. 2. Miasmatic, in which the germ has no connection with any previous human body. 3. Miasmatic contagions (the existence of which is doubtful), in which the germ has to undergo development after passing out of one body before it can produce the disease in another. Typhoid Fever. Definition.—An acute infectious disease characterized anatomi- cally by inflammation and ulceration of Peyer's patches. Synonyms.—Enteric fever; abdominal typhus. Prevalence.—Universal. Causes.— 1. Germ, bacillus; in length one third the diameter of red blood corpuscles, width one third its length, motile, contains spores, stains with Bismarck brown, does not liquefy gelatine in culture experiments; the germ has rounded ends and may be PRACTICE OF MEDICINE. 37 straight or curved. It is found especially in foecal discharges and in albuminous urine of typhoid patients. Resists cold and heat. 2. Contagious if germs get into the body by (i) intestinal canal; (2) respiratory organs. 3. Media of Contagion. (1) Drinking water; (2) milk and, possibly, meat; (3) air, if foeces are allowed to dry without being disinfected. 4. Favorable conditions for life and development of the germ out- side of the body are filth and moisture, but germ may live in the dry state. The germ may live in ice for months, but requires warmth for its development. 5. Season of the year. The disease is most common in the summer or autumn, because the temperature is favorable for devel- opment then, and the decomposition of vegetable and animal mat- ter also furnishes favorable conditions. 6. Age. Most common between the ages of fifteen and thirty; probably, because persons of this age are more apt to meet with the germ in travel, &c. 7. Period of incubation—usually about three weeks, but may be much less. Morbid Anatomy.—/. The spleen is enlarged and softened, be- cause the germs or leucomaines are conveyed to it in the blood and causes congestion and multiplication of cells. 2. The liver and kidneys and heart and muscular tissue undergo albuminoid degeneration in consequence of the irritation set up by the leucomaines in the blood; the liver is especially involved, be- cause the leucomaines are carried directly there by the portal circu- lation, and the kidneys are especially affected, because the leuco- maines are eliminated by them. 3. The larynx, bronchi and lungs are often inflamed because toxic matters are inhaled from the mouth. 4. The brain and nervous system generally show few morbid ap- pearances. Meningitis is occasionally present, because of its inti- mate connection with the lymphatic system, and the germs are dif- fused through the lymphatics. 5. The intestines. The germ usually enters through the mouth; the stomach is but little affected because its acid juice interferes with the development of the germs. The upper part of the small intestine is but little involved, because the bile interferes with the development of germs. The lower part of the small intestine is affected, because the contents of the bowel are alkaline there, the bile has been reabsorbed, and the foecal matters stagnate there in consequence of the obstruction at the ilio-caecal valve. Peyer's 38 PRACTICE OK MEDICINK. patches are especially involved, because the germs are arrested in them. These patches become red and swollen from the increased amount of blood in the vessels, the exudation of serum and the accumulation of leucocytes. This occurs during the first week. In the second week the cells in the patch die from the direct action of the germs and leucomaines and from coagulativc necrosis, and a slough is formed which is discharged during the third week, leaving an ulcer which usually heals without narrowing of the in- testine, but which may eat into a vessel and cause hemorrhage or perforate into the peritoneal cavity. 6. The mesenteric glands are frequently inflamed and enlarged, because the germs pass to them from Peyer's patches, are arrested in them and set up inflammation. They may undergo resolution, caseation and calcification, or may soften and burst into the peri- toneal cavity. Symptoms.—A. Prodromic or Premonitory—not characteristic. Anorexia, headache, chilliness, weakness, and pain in the back and limbs. Bleeding from the nose is quite frequent and suggestive along with the other symptoms. B. Symptoms of developed attack— i. Temperature; gradual rise of 1° each day during the first week, the evening temperature being i° higher than the morning temperature of the same day. In the second and third weeks a morning temperature of about 1030 or 1040 and an evening tem- perature of 1040 or 1050. During the fourth week a gradual fall of temperature, the morning temperature being much lower than the evening temperatures of the same day. A sudden termination ot the high temperature is very rare, and a sudden fall generally in- dicates hemorrhage from the bowel or peritonitis. Occasionally, especially in children, the temperature rises suddenly. 2. Circulatory symptoms. The pulse is usually from 90 to 100 during the first week. Alterwards it becomes rapid and weak, and sometimes irregular, in consequence of albuminoid degeneration of the heart and muscular coat of the arteries, and, probably, also, in consequence of action of the leucomaines on the intrinsic ganglia of the heart or the vagus nerve. 3. The skin is usually hot and dry, but may be wet with sweat when the temperature is high. The amount of heat formed is al- ways above the normal, in consequence of the action of the leuco- maines on the heat centres. The sweating sometimes seen is prob- ably due to a paralysis of the inhibitory sweat centres. An eruption of rose-colored spots, few in number, pink in color, about one-eighth inch in diameter, not raised and disappearing tem- porarily on pressure, is occasionally seen, especially on the chest and abdomen. Each spot lasts for three days and then disappears. PRACTICE OF MEDICINE. 39 Blood drawn from them shows many typhoid bacilli. Probably a few germs are discharged by the skin. 4. The urinary symptoms are, scanty and high colored urine, sometimes containing albumin. It is scanty because the blood pressure is lowered ; it is high-colored because the bacilli destroy red corpuscles and consequently more pigment is discharged by the kidneys. The occasional presence of albumin is owing to a slight nephitis, caused by the elimination of leucomaines by the kidneys. 5. The nervous symptoms are headache, delirium, which may be mild, or low and muttering, subsultus tendinum, and diminished reflexes. These symptoms are due to poisoning by leucomaines. Deafness is not unusual in some cases, and is due to the action of the leucomaines on the nerve centres chiefly, but in part also to inflammation of the eustachian tube. 6. The digestive symptoms are anorexia, sometimes nausea and vomiting, diarrhoea, tympanitis, gurgling in right iliac fossa, and sometimes hemorrhage. Occasionally sudden and violent pain. The anorexia and nausea are probably due to the action of leuco- maines on the nerve centres ; the diarrhoea to the irritation of the bowels by the germs and a serous exudate in consequence ; the tympanitis to the fermentation of the contents of the intestine a^d the loss of tone about the muscular coat of the bowels which per- mits them to become distended with gas. Gurgling is probably due to the presence of fluid and gas in the coecum or adjacent parts of the intestine. Hemorrhage is due to the opening of a vessel by ulceration. Sudden and violent pain followed by collapse indicates perforation of the bowel. The tongue is at first coated white and is red at tip and edges; later, brown and dry and cracked. The teeth are covered with sordes from drying of bloody mucus. 7. The general symptoms are emaciation and prostration, due to defective nutrition and excessive oxidation and waste. Symptoms in Atypical Cases.— The fever may rise suddenly and such cases usually run a rapid and favorable course. The temperature may be of moderate intensity, about 101° or 102° throughout the attack. Such cases are tedious but usually end in recovery. In such cases, as a rule, there is constipation and but little delirium. Constipation is often present even in severe cases. The erup- tion is very often absent. Diagnosis.—Often difficult in early stages and even through- out the attack in mild cases. Distinguished from (1) acute tuberculosis by the extensive crepi- tation in the chest in the latter, (2) typhoid pneumonia by the fact that in the latter the pneumonia precedes the typhoid symptoms, 40 PRACTICE OF MEDICINE. (3) gastroenteritis by the different temperature curve in the two diseases. Prognosis.—Dependent on—1. Type. 2. Duration. 3. Temperature. 4. Complications. 5. Age. Less fatal in children than adults. Complications.— 1. Pneumonia from inhalation of morbid mat- ters from the mouth. 2. Bed sores from pressure and action of germs. 3. Parotitis from entrance of germs into parotid gland through its duct. Duration.—From three to five weeks — sometimes abortive when it lasts only ten days or two weeks. Relapses occasionally occur, probably from reinfection. Sequelae. — 1. Ncri'ous, sometimes intellectual weakness of tem- porary character; occasionally permanent. 2. Muscular.—Atrophy ot certain muscles occasionally occurs. ^Causes of Death.—1. Toxaemia, from large amount of pto- maines formed. 2. Exhaustion, from fever, diarrhaa or long duration after the attack. 3. Hemorrhage, from ulceration of a vessel. 4. Peritonitis, from passage of germs into abdominal cavity with or without preforation. Treatment.—A. Prophylactic, attention to be paid to water supply, sewer pipes, &c, to prevent contamination with germs. Faral discharges to be disinfected by solution of bichloride of mercury, 1 to 500, or chloride of lime, 1 to 100. Bed clothes to be disinfected by soaking in bichloride solution, 1 to 1000, and subsequent boiling. B. General management. — 1. Room should be large, to furnish fresh air. 2. Patient should be kept in bed strictly, because movement in- creases exhaustion. 3. Diet should be liquid and nutritious, such as halt a glass of milk or fresh buttermilk every four hours. C. Medicinal treatment directed— 1. To reduce temperature, if over 1030, by cold or cool baths, unless hemorrhage has occured, when they are dangerous, antipy- rine, antifebrine, phenacetine, and quinine. 2. To sustain strength, by stimulants and nourishment. Stimulants not always necessary. If they cause quickening of PRACTICE OF MEDICINE. 41 the pulse, the quantity should be diminished, or they should be stopped altogether. D. Specific treatment is intended to kill the germ. It is of doubtful value. The germicides which have been used are— 1. Calomel. 2. Iodine. 3. Carbolic acid. 4. Corrosive sublimate. 5. Naphthaline, &c. In many cases of a mild character no medicinal treatment is necessary; but the importance of care in diet cannot be exagger- ated. Perforation of the bowel may occur from imprudence in the mildest cases. Absolute rest in bed is of almost as great impor- tance. Treatment of Special Symptoms and Complications.—1. Diarrhoea.—Opium, bismuth and other astringents to check secre- tions and naphthalin to check fermentation and probably destroy germs. 2. Tympanites.—Turpentine internally and turpentine stupes to stimulate the muscular coat of intestine. Aspiration and the insertion of a tube into the rectum to withdraw the gas. 3. Hemorrhage.—Opium to paralyze the muscular coat of the bowels and absolute quiet to allow a clot to form. Ergot to cause contraction of the vessel and turpentine for the same purpose. 4. Peritonitis.—Opium to relieve pain and paralyze the bowel so as to prevent escape of foecal matter as far as possible. Laparotomy has not given good results because the patients are already ex- hausted. 5. Bronchitis and pneumonia to be prevented by cleansing the mouth frequently; treated chiefly by stimulants and dry cupping. Stimulants help the heart to force the blood through the diminished respiratory space. 6. Bed sores to be prevented by frequent changing of position, air bed and sponging with alcohol and corrqsive sublimate; treated antiseptically by bichloride solution 1 to 2000 or 4000 and iodo- form ointment. 7. Constipation to be relieved by enemata because of the danger of profuse diarrhoea or perforation if purgatives are used. 8. Delirium, if mild, to be treated by cold to the head, phenace- tine or opiates; if low and muttering, by stimulants and opium. Sleeplessness to be treated by opium, paraldehyde, and if the pulse is full and strong, by chloral. Management and Diet During Convalescence.—Patient should remain in bed and take liquid food only for at least a week after the evening temperature is normal because of the danger of preforation of the bowel. 6 42 PRACTICE OF MEDICINE. , Typhus Fever. Definition.—An acute infectious disease characterized by a rapid rise of temperature which lasts about two weeks and then suddenly declines, violent headache followed by delirium and a macular eruption which appears on the fifth or sixth day and persists until the end of the attack. Synonyms.—Jail fever, ship fever, spotted fever, &c, &c. Causes. — I. A germ probably, but it has not yet been discov- ered. The germ seems to require filth for its existence outside of the body. 2. The favorable conditions for the communication of the dis- ease are over-crowding and bad hygienic surroundings and also the concentration of the poison or germs. Over-crowding and bad hygiene act by diminishing the resisting power of the individual and probably also by furnishing a suitable soil for the life of the germ. When the poison is concen- trated or the germs numerous it is probable that the phagocytes cannot dispose of them. 3. The avenue of introduction is the respiratory mucous mem- brane. 4. The medium of contagion is the air — the exhalation from the lungs and probably Irom the skin. 5. One attack confers immunity as a rule from subsequent at- tacks. 6. The period of incubation is usually about two weeks. Morbid Anatomy.— 1. The blood is dark in color and deficient in fibrin factors, probably from the action of the bacteria or leuco- maines. 2. The heart and general muscular tissue, liver and kidneys show albuminoid degeneration and the spleen is enlarged as in the other acute infectious diseases and for the same reason. 3. The lungs are frequently inflamed from the inhalation of de- composing substances from the mouth or from the circulation through them of leucomaines. 4. The blood vessels of the brain are engorged and often there is a serous exudate. 5. There are no characteristic changes in the intestinal canal. Complications.—I. Bronchitis, pneumonia and somixme*pulmo- nary ojdema and also pleurisy. The occurrence of the former has been already explained. The latter is due to the connection of the pleural cavity with the lymphatic system. 2. Meningitis occasionally occurs for the same reason that pleu- risy does. 3. Glandular enlargements are due to the passage of bacteria and leucomaines through the lymphatic vessels and their temporary arrest motherlands with consequent inflammation. PRACTICE OF MEDICINE. 43 4. Thrombosis of the veins of the lower extremity is due to pres- sure on the veins by enlarged glands and defective nutrition of the vascular walls. Symptoms.—1. Mode of outset is sudden. 2. Nervous symptoms, chills, headache, backache, delirium, stu- por and coma vigil due to poisoning by leucomaines. 3. The temperature rises suddenly to I03°-I05°, or even 1060, and falls in favorable cases on nth to 14th day. The fever is due to the action of leucomaines on the heat centres in the brain. 4. Digestive symptoms. Sometimes there is nausea, probably central in origin and due to the action of leucomaines on the brain. Constipation is due to albuminoid degeneration and weakening of the muscular coat of the bowels. 5. Circulatory symptoms. The pulse ranges from 100 to 130 usually ; the increased rapidity is due to increased temperature and probably also to direct action of leucomaines ; it soon becomes soft and compressible from changes in the heart and vessels. 6. Cutaneous symptoms. An eruption appears on the 5th or 6th day on chest and abdomen, macular in character, dark in color and each spot lasts throughout the disease. 7. Urinary symptoms. Albuminuria, diminution in quantity and complete suppression may occur from the changes in the kidneys. There may be retention of urine from paralysis or benumbing of nervous sensibilities. Diagnosis from—1. Meningitis, made by the presence of a rash in typhus fever and the greater prostration and more, rapid pulse. 2. Typhoid fever, by the absence of diarrhoea, the different course of the temperature, and the difference in the eruption. 3. From relapsing fever, by the eruption of typhus, and the absence of relapses. Prognosis.—The prognosis is based on age, the mortality in children being very low; previous health and habits as to temperance. It is exceedingly fatal in the intemperate, because the kidneys are often diseased" in such persons, the blood-vessels are degenerated and the resisting power of the tissues generally is impaired. Causes of Death.—1. Toxczmia, from the amount of poison (leucomaines) formed. 2. Syncope, from the action of the leucomaines on the muscular tissue of the heart and probably on the intrinsic ganglia. 3, Complications, such as pneumonia and meningitis. Duration.—Usually about fourteen days, when the disease ter- minates by crisis. Treatment.—A. Preventive—\. Quarantine. 2. Disinfection of the room or house with sulphurous acid or chlorine. 44 PRACTICE OF MEDICINE. 3. Ventilation, which seems to scatter the germs so that only a few are taken into the body, and they are probably destroyed by the phagocytes. B. Remedial.—The indications are— 1. To neutralize the poison, which can best be done by fresh air. 2. To reduce the temperature by cool sponging, phenacetine, &c. 3. To sustain strength by food and stimulants, if the latter do not increase headache and quicken the pulse ; if they do, they should be discontinued. Relapsing Fever. Definition.—An acute, infectious and contagious disease, char- acterized by high fever, great prostration, rapid apparent recovery, and after a week or ten days a relapse. Synonyms.—Famine fever—recurrent typhus. Causes.—The essential cause is the bacterium known as the spi- rillum obermeieri, which is found in the blood during the attack, and is motile. It is propagated by contagion ; enters by the respi- ratory mucous membrane; one attack is protective. Incubation from one to seven days. Morbid Anatomy.—Not characteristic. The changes common to the acute infectious diseases are found. Symptoms.— 1. Nervous; chill, headache, pain in the back and limbs from poisoning. 2. Rapid rise of temperature to 1040 to 1070 from action of leu- comaines on the heat centre. 3. Digestive.—Nausea and vomiting, constipation. 4. Circulatory.—Rapid and feeble pulse from condition of heart and vessels. 5. Remission and relapse from causes which are not known. Diagnosis, based on prostration, character of the fever, absence of eruption of typhus, and relapse. Prognosis is very good; mortality about 3 per cent. Treatment.—Indications.—1. To relieve pain and reduce fever, by phenacetine, antipyrine, &c. 2. To guard against syncope, by absolute quiet. Scarlet Fever. Definition.—An acute, infectious and contagious disease char- acterized by a rash at first punctate and not raised, which runs a definite course and is followed by desquamation. PRACTICE of medicine. 45 Varieties.—I. Simple, when it pursues a mild course. 2. Malignant, when it pursues a very severe course. Causes.—.1. A germ is almost certainly the essential cause, but it has not yet been discovered with certainty. 2. Media of Contagion, the atmosphere, clothing, letters, milk animals, &c, the germ being contained in the mucous secretions, blood and epidermic scales. 3. Avenues of Introduction, the lungs, the stomach and the skin (by inoculation.) 4. Immunity is conferred by one attack, as a rule, against subse- quent attacks. 5. Age—It is rare in children under six months old and in adults. 6. The period of incubation is from a few hours to ten days. Morbid Anatomy. — 1. The changes common to the acute in- fectious diseases are found in scarlet fever. 2. The skirt exhibits an eruption, at first punctate in character afterwards becoming diffused; 2. The tonsils and throat are inflamed and swollen, and the tis- sues of the neck may be infiltrated with sero-fibrinous exudate or abscess may form in consequence of the passing of the germs from the throat into the lymphatics and tissues. 3. The glands around the throat may be inflamed and swollen from the same cause. 4. The kidneys are often inflamed from the elimination of germs and leucomaines through them. Symptoms.—A. Prodromic. Sore throat is the most conspic- uous, due probably to the arrest of the germs there and the pres- ence of favorable conditions for their development and growth. B. Developed. 1. Nervous. Those characteristic of the acute infectious diseases already mentioned. 2. The temperature rises rapidly to 103 or 105; the skin feels singularly hot. 3. Circulatory. The pulse is very rapid and becomes weak. 4. Digestion. Nausea and, sometimes, vomiting; strawberry tongue, from enlargement of the papillae. 5. Eruption, which appears on the second day, first on the neck and chest, is scarlet in color, punctate at first, and then becomes uniform by coalescence, begins to fade on the fourth day, and des- quamation begins on the 6th or 8th day and lasts two weeks. Malignancy may take the form of toxaemia, a very high tem- perature, a dark eruption or great involvement of the throat. Mild cases may occur with and without eruption. Peeling may occur when there has been no eruption and such cases may cause others of malignant character. 46 PRACTICE OF MEDICINE. Complications.—i. Nervous convulsions or mild delirium or stupor may occur from (i) poisoning by leucomaines, (2) interfer- ence with the circulation by swelling of the tissues of the neck, (3) unemia. 2. Otitis media.—Inflammation of the middle ear is common from the germs passing up through the eustachian tube. Deafness often ensues and young children may be dumb also in consequence. 3. Diphtheria is an occasional complication. Sequelae.— 1. Nephritis, leading to more or less extensive drop- sy, is common and is probably due to the irritation of the kidneys by the leucomaines during their excretions by these organs. 2. Inflammation of serous membranes, especially the endocar- dium, is of comparatively common occurrence and is due to the leucomaines in the blood. Pleurisy and rheumatism are also occasional sequelae. Rarely there is suppurative inflammation of the joints. Diagnosis.—1. From measles it is distinguished by the absence of the premonitory coryza and the punctate or non-elevated erup- tion. 2. From small-pox by the difference in the eruption, absence of vesicles or pustules. 3. From erythema and roseola by the absence of punctate red- ness at any stage of the latter affections. 4. From diphtheria by the eruption in scarlet fever; if there is no eruption a diagnosis is extremely difficult. Prognosis.—The prognosis is always uncertain ; the mortality ranges from five to twenty per cent. It is greatest in children be- tween one and five years of age. It is further dependent on (\) the character of the epidemic, (2) the severity of the throat lesions, (3) the height of the temperature. Treatment.—A. Prophylactic.— 1. Isolation is by far the best. 2. Disinfection of the room and clothing by chlorine gas and solution of bichloride of mercury is essential. 3. Boracic acid, possibly, may prevent the disease in children who are exposed to it (Lewis Smith). 4. Oiling the surface of the body prevents the scales from being disseminated as readily by the atmosphere, and hence acts as a prophylactic. 5. Ventilation is always advisable. 6. Belladonna is useless. B. Medicinal.—1. To neutralize the poison of the disease as far as possible by ventilation ; boracic acid may lessen the virulence of the poison also. Bichloride of mercury and muriated tincture of iron are used for the same purpose. •PRACTICE OF MEDICINE. 47 2. To reduce fever by cold sponging, cold baths if the tempera- ture is over 105, (there is more danger of nephritis probably when cold baths are used), phenacetine, acetanilide, &c. 3. To promote the action of the skin by sponging with tepid wa- ter. 4. To relieve itching and burning by sponging with tepid water, or saline solution, or weak alcoholic solution. 5. To relieve throat complications by the use of sprays of lister- ine or carbolic acid, &c, or by the administration of bichloride of mercury and muriated tincture of iron in glycerine. 6. To prevent nephritis, by promoting the' action of the skin and by the avoidance of chilling of the surface. 7. To sustain strength by suitable food and stimulants. Diphtheria. « Definition.—An acute, infectious and highly contagious disease characterized anatomically by the formation of a false membrane on some of the mucous surfaces, especially that of the pharynx. Causes.— I. A germ, probably a streptococcus, which finds fa- vorable conditions for its development outside of the body in filth, especially sewage. The favorable conditions for the occurrence of the disease in an individual are depression of the general health and some inflam- mation, acute or chronic, of the pharyngeal mucous membrane. The avenues of introduction of the germ are (1) the respiratory mucous membrane ; (2) the mucous membrane of the mouth and throat; (3) probably also an abraded surface. The media of contagion are: (1) the atmosphere; very often sewer gas contains the germs of diphtheria ; (2) the mucous secretions and probably the blood; (3) clothing and other substances, and also animals ; it is prob- able that certain animals, especially birds, are liable to this disease and may communicate it to man. 2. Age. The disease is more common between the ages of six months and two years, but may occur at any period of life. 3. One attack pf diphtheria does not confer immunity from subsequent attacks. 4. The period of incubation is from one to eight days, rarely longer. Morbid Anatomy.—1. The false membrane— (1) Its situation. It may be found on any mucous surface, or any abrasion or wound ; (2) mode of formation and structure. It consists of epithelial cells and leucocytes, which are granular and degenerated, entangled in a network of fibrin. A croupous membrane is on the surface of the mucous membrane; a diphtheritic membrane is not only on the 48 PRACTICE OF MEDICINE. surface, but extends into the substance of the mucous membrane. The membrane is formed by coagulation necrosis and by the exudation of fibrin ; (3) color and thickness. The color is an ashy gray, and the membrane is often a fourth of an inch in thickness; (4) bacteria of various kinds are formed in the membrane. The coccus forms predominate ; (5) the mode of removal of a diphtheritic membrane is by absorption, suppuration or gangrene. The membrane is so closely adherent to the tissues that it can- not be removed without tearing it off, and after being removed in this way it soon returns. It may undergo absorption in mild cases, softening first occur- ring, and the softened material is taken up by the lymphatics and blood vessels. Suppuration often occurs, the membrane being thus loosened from the tissues beneath it. Gangrene may occur in bad cases from the pressure upon the blood vessels, and probably also from thrombosis of the vessels in the inflamed tissues. 2 The heart, kidneys, muscles and liver show albuminoid degen- eration which may pass into fatty degeneration. 3. The spleen is enlarged and the lymphatic glands in the neigh- borhood of the inflamed surface are inflamed and swollen. The tissues around the glands are also inflamed and swollen ; the in- flammation is due to the action of the germs and the leucomaines formed by them, and the swelling is due to the exudate. 4. The brain and nervous system are often involved. A neuritis is frequent, which is probably due to the action of leucomaines, but the morbid changes in the nervous system are not clearly under- stood. Symptoms.—The symptoms present no typical course, but vary greatly in character and intensity in different cases. A. The local symptoms : 1. When the pharynx is involved, are redness of the throat, which is very dark in color and often circum- scribed ; later on, an ashy membrane forms on the tonsils or pha- rynx ; there is some pain but in many cases it is not severe. The glands of the neck are swollen and the tissues infiltrated with in- flammatory exudate, because the germs have passed from the mu- cous membrane of the throat to the glands, been arrested there and set up inflammation. They have gone into the surrounding tissues through the lymphatic vessels. 2. When the nose is involved, it is stopped up by the swollen mucous membrane and the false membrane ; there is a serous and often slightly bloody discharge which excoriates the upper lip on which a false membrene torms. The tissues underneath the angle of the jaw are greatly swollen. PRACTICE OF MEDICINE. 49 3. In laryngeal diphtheria there are difficulty of breathing, a hoarse muffled cough, blueness of the skin, sometimes convulsions follow- ed by coma and death. All these symptoms are due to the forma- tion of false membrane on the vocal cords which prevents the en- trance of air and the proper oxygenation of the blood. B. The constitutional symptoms vary very much in different cases. 1. The temperature has has no typical course; it may reach 1030 or 1040, or it may not be elevated above ioo°. The degree of temperature has no prognostic significance. 2. The circulatory symptoms are often striking. As a rule the pulse becomes very feeble and rapid, but in some cases after the membrane has disappeared from the throat the pulse may become very slow, sometimes falling to thirty beats per minute. Such cases rarely recover. The weakness of the pulse is due chiefly to the albuminoid or fatty degeneration of the heart. The change in the number of beats is due in all probability to nervous influence, but it is not known what the changes in the nervous system are. 3 The digestive symptoms are anorexia and sometimes nausea and vomiting. These symptoms are probably due to the action of the leucomaines on the nerve centres. 4. The icrinary symptoms. In many cases there is albuminuria, and sometimes casts are found in the urine. 5. The general symptoms are prostration,which is often extreme, and, in many cases, pallor. Complications.—Pneumonia is not uncommon. It is due to the inhalation of noxious matters from the mouth, larynx and bronchi, the diphtheritic process often extending into the bronchial tubes. Conjunctivitis is apt to occur either by extension through the tear duct or by some of the discharge from the mouth getting into the eye. Otitis media is a common complication, the germs passing up through the eustachian tube. Gangrene of the fauces and tissues of the neck occurs in bad cases from pressure on the blood vessels and thrombosis and proba- bly also from the immediate destruction of the tissues by the con- centrated leucomaines. Inflammation of serous membranes may occur as in the other acute infectious diseases. The manner in which they are pro- duced has already been explained. Sequelae.—1. Paralysis is the most common and striking se- quel. The parts usually involved are the muscles of the palate and of the eyes. Sometimes the muscles of the extremities and body are affected. The tendon reflexes are lost. The paralysis is proba- bly due to a degenerative neuritis, but it is not clearly understood. Unless the heart or the muscles of respiration are involved, diph- theritic paralysis nearly always terminates in recovery. 7 50 PRACTICE OK MEDICINE. 2. Parenchymatous nephritis sometimes occurs in consequence of the elimination of the leucomaines by the kidneys. 3. Deafness may be caused by the closure of the eustachian tube from cicatricial contraction, or it may be due to the loss of the drum-head and the small bones of the ear. Diagnosis.—1. Follicular pharyngitis causes sore-throat and the tonsils often present upon their surface yellow or white spots or a yellow coating; but this coating is readily removed by a brush while the membrane of diphtheria Is not. 2. Scarlet fever also causes sore throat, but nearly always there is the characteristic eruption and there is, as a rule, no false mem- brane. Prognosis.—The prognosis of diphtheria is always uncertain, even from hour to hour. It is dependent on 1. Age, the mortality being greatest between the ages of six months and ten years. 2. Character of the epidemic. 3. Complications. 4. Involvement of the larynx. Recovery in cases of laryngeal diphtheria, unless the patient is subjected to tracheotomy or intuba- tion, is exceedingly rare. 5. Location and atmospheric conditions. The mortality is very great in high and cold situations. Causes of Death.—1. Toxarnia, from the amount of leuco- maines absorbed. 2. Asphyxia, from obstruction of the larynx, or from paralysis of the respiratory muscles. 3. Exhaustion, from defective nutrition and heart failure. 4. Paralysis of the heart. 5. Complications. Treatment.—A. Prophylactic. 1. Isolation, to prevent the com- munication by direct contagion. The germs are not carried far by the atmosphere. 2. Disinfection of sputa and discharges by bichloride of mer- cury, &c. 3. Disinfection of clothing by bichloride of mercury solution or chloride of lime and by boiling. 4. Disinfection of the room by washing the walls with bichlo- ride solution and by fumigation with chlorine or sulphurous acid. B. Remedial— 1. Constitutional—(1) to sustain strength by alcohol and nutri- ment and by muriated tincture of iron, &c.; (2) to destroy or 'weaken the germs (?) by the use of bichloride of mercury in large doses, and benzoate of soda, &c, &c. 2. Local.—(1) To reduce inflammation as far as possible by hot PRACTICE OF MEDICINE. 51 application or poultices applied to the neck. No counter-irritants should be used because the false membrane forms readily on an abraded surface. (2) To dissolve or loosen the false membrane, by inhalation of steam, turpentine, carbolic acid, or by sprays of carbolic acid, lime water, lactic acid, trypsin or papayotin. The three latter agents will help to dissolve the membrane. (3) To disinfect the throat by bichloride of mercury, carbolic acid, listerine, &c. Nasal diphtheria is to be treated by frequent and thorough syr- inging of the nose with antiseptic solutions. Laryngeal diphtheria should be treated by— (1) intubation, or (2) tracheotomy. The percentage of recoveries is about the same after each opera- tion, namely, twenty-eight. Dysentery. Definition.—An acute infectious disease characterized by inflam- mation of the large bowel and frequent actions of mucus and blood. Forms.—The disease may be epidemic or sporadic and it may be acute or chronic. A disease precisely similar in symptoms and morbid anatomy to infectious dysentery, and which is commonly called dysentery, may be caused by constipation and other things without the di- rect action of germs so far as our present knowledge is con- cerned. Causes. — 1. A germ in all probability is the essential cause of acute epidemic dysentery, but it has not yet been discovered. 2. The favorable conditions for the development of the infective agent are warmth, moisture and filth, hence the disease is most common in hot climates or hot seasons, in damp localities and where animal or vegetable matters are undergoing decomposition. 3. The avenue of introduction is the alimentary canal. 4. The medium of conveyance is usually water. The germ is discharged from the body with the faeces and if these germs gain access to the drinking water the disease will occur in those using such water. The germ, like that of typhoid fever, is apparently de- stroyed, or at any rate rendered inert, by drying. Morbid Anatomy.—1. The large bowel is the part involved. The change there is inflammatory in character. Redness, swelling and exudation occur. The cause of these has frequently been^-ex- • 52 PRACTICE OF MEDICINE. plained. The exudation is usually fibrinous in character and leads to sloughing, and the solitary and agminated glands, when the germs are arrested, become inflamed, swollen and ulcerated. Later the ulcers heal and cicatricial contraction results. 2. Complicating conditions of occasional occurrence are abscess of the liver from the lodgment in that organ of the septic emboli, brought by the portal vessels from the large bowel, and inflamma- tion of serous membranes, which are occasionally seen in all the acute infectious diseases. Symptoms.— I. Nervous. A chill often occurs at the com- mencement, pain and tenderness over the region of the large bowel in consequence of the inflammation there. 2. Digestive. The appetite is lost, probably from the action of the toxic matters generated by the germs. The tongue is heavily coated usually, and, if the case assumes a typhoid character, it be- comes brown and dry, and sordes collect on the teeth. Often there is troublesome nausea and vomiting. The stools are at first fecu- lent, but soon consist of blood and mucus. The quantity dis- charged each time is small but the actions are frequent. The blood comes from the bursting of the engorged vessels and ulcera- tion, the mucus from the excessive secretion in the large bowel. The frequent desire to evacuate the bowel and the straining or tenesmus at the time is due to increased reflex excitability in conse- quence of inflammation. 3. The temperature is elevated, being usually between 1030 and 104°. 4. The circulatory symptoms are, rapidity of the pulse, which, however, is not very marked in the early stages ; but later there is great frequency and feebleness from the changes in the heart muscle, which are common to all infectious diseases. 5. The urinary and vesical symptoms are often very marked; the urine is scant and dark colored, and there is frequent desire to pass water with spasm at the neck of the bladder, which is reflex in character, and is due to the inflammation of the rectum. In malarial sections, or in persons who have suffered with ma- laria, the disease assumes an intermittent or remittent character. Diagnosis.— I. From acute intestinal catarrh dysentery is dis- tinguished by the absence of mucus and blood and cf tenesmus in the former disease. 2. From diarrhwa complicated with hemorrhoids it is distin- guished by the faecal character of the discharges in diarrhoea and the absence of tenesmus. Course.—Dysentery usually pursues a typical course and the duration of the attack is about ten days. PRACTICE OF MEDICINE. 53 Prognosis.—The prognosis depends on—i. The type of the disease. 2. The previous health of the patient. 3. The complications. As a rule the disease ends in recovery, but may assume a chronic form. Treatment.—Prophylactic. The prophylactic treatment is pre- cisely the same as that of typhoid fever, and consists in purification of the water if contaminated, disinfection of the stools and cloth- ing and the avoidance of cold and dampness and ot improper food, both of which are liable to cause congestion of the bowels and thus render them more vulnerable. Remedial treatment consists in—I., Sustaining strength by nourishing food and stimulants. 2. Removal of offending matters, such as scybala from the bow- els by saline aperients, castor oil or enemata. 3. Relieving pain by hot applications to the abdomen, opiates and bismuth. 4. Checking the discharges by opium and bismuth and astrin- gents. 5. Disinfecting the bowel by means of bichloride of mercury or naphthalin or by enemata or by chloride of mercury or by irriga- tion of the bowe^ with simple water. 6. Specific treatment with ipecac which is sometimes given in large doses, but seems equally beneficial in smaller quantities. In chronic dysentery injections of silver nitrate are very useful. Epidemic Cholera. Definition.—An acute infectious disease, characterized by pro- fuse watery action from the bowels, great prostration and cramps in the limbs. Distribution.—Its home is in India, and it is a disease of hot countries chiefly. Synonyms.—Asiatic cholera, or simply cholera. Causes. — 1. A germ which has been completely identified is the essential cause. This germ is a curved bacillus, and is hence called the comma bacillus; it is about half the length of the bacillus tuberculosis, and is motile. The germ is found in the discharges from the bowel and in the contents of the bowel after death, but not in the walls of the intestines. 2. The favorable conditions for development are moisture, which is essential to the life of the germ, a certain degree of warmth and organic matter. Sewage is a very favorable soil for the develop- ment. 54 PRACTICE OF MEDICINE. 3. The avenue of introduction is in all cases, perhaps, the ali- mentary canal. 4. The medium of conveyance is in all, or nearly all, cases, per- haps, drinking water ; because the germ is contained in the faecal discharges, and the water is liable to be contaminated by them ; but persons handling the moist clothes of cholera patients may get the germs on their hands and thus get them in the mouth, and con- tract the disease in this way. 5. The period of incubation is from a few hours to a few days. Morbid Anatomy.— 1. The general appearance of the body is very striking ; it is very white and shrivelled. 2. The small intestine is softened somewhat, its epithelium is in part desquamated, and it contains a rice-water fluid with flakes of epithelium in it. 3. The kidneys are small and dark, and the bladder is empty be- cause of the loss of fluid. 4. The lungs and bronchi are also much harder and dryer than usual for the same reason. 5. The heart and spleen undergo a similar change, the latter or gan being smaller than normal, on account of the loss of water from the body. Symptoms.—Prodromic, or 1st stage. The prodromic symp- toms are slight, and consist of a painless diarrhoea. This is fre- quently called the first stage. In the 2nd stage the symptoms are well mariced. 1. Digestive.— There are profuse water actions at first contain- ing some faeces and bile, but later resembling rice water in appear- ance and being devoid of odor. They contain a very large amount of albumin. Vomiting also occurs, large quantities of fluid being ejected. The profuse watery discharges are probably due to a paralysis of the nerves of the bowel from the action of the toxic substance generated by the comma bacilli. 2. The temperature is elevated, but is not usually very high, and the extremities feel cool in consequence of the extreme feebleness of the heart and the loss of the water from the blood. 3. The pulse is \tery rapid and feeble in consequence of defective nutrition of the heart muscle and the changes in that organ, and probably also in consequence of the direct action on the heart of the toxic substance. 4. The urine is scant and high colored, because the blood press- ure is lowered and but little water passes out through the kidneys. 5. Nervous and special sense symptoms are present. There are violent cramps in the limbs and body, especially in the calves of the legs, and the sufferers may become deaf and blind. The second stage lasts from one to two days. In the 3rd or algid stage all the symptoms are aggravated. The PRACTICE OF MEDICINE. 55 discharges from the bowels continue, the pulse becomes imper- ceptible, the extremities are cold and there is suppression of urine. This stage rarely lasts more than six or eight hours and is succeed- ed by death or the reactionary stage. Reaction is often rapid, and is marked by improvement in all the symptoms. Cholera typhoid may come on after reaction has occurred. The temperature rises, the bowels become loose again and the actions are often bloody, and these are the usual typhoid symptoms. Occasionally cholera nephritis occurs and causes death by urinae- mic poisoning. Diagnosis—I. Arsenical poisoning is distinguished from chol- era by the absence of blood and feculent matter in the actions in the latter disease, but there is often a striking similarity between the two. 2. From gastro-enteritis cholera is distinguished by the different character of the actions and by the difference in the course of the two diseases. Prognosis.—The mortality varies from twenty to eighty per cent. As a rule the whole course of the disease is rarely more than five or six days, though reaction is occasionally slow. Treatment.—Prophylactic treatment consists in—1. Quaran- tine. 2. Disinfection of stools by bichloride solution and of clothing by dry heat. 3. Drainage and cleanliness. 4. Diet. The utmost prudence should be observed during a cholera epidemic. Remedial treatment consists in I. Controlling the premonitory diarrhoea by quiet, opium and astringents. Large enemata of tan- nic acid seems to be especially efficacious and are thought to de- stroy the comma bacilli. 2. Relieving symptoms by stimulants, warmth to the extremities and suitable diet during reaction. Yellow Fever. Definition.—An acute, infectious disease, conveyed by fom- ites, occurring usually in hot countries, and characterized by a fever of short duration, usually yellowness of the skin, great prostration and in some cases "black vomit." Causes.—The essential cause is almost certainly a germ, but it has not yet been discovered with certainty, 2. Thefavorable conditions for its development are warmth, mois- ture and filth. Overcrowding is also a factor in its production. 56 PRACTICE OF MEDICINE. Cold destroys the germ, the first frost usually causing an ab- rupt termination of an epidemic. 3. Modes of conveyance of the poison. ' The germ may be car- ried by persons sick with the disease in clothing, hair and probably in letters. It is also carried in the atmosphere, but seems to be con- fined to the lower strata, and is readily stopped by streams, forests or even streets. 4. With respect \orace\X. has been found that negroes are less liable to the disease than white persons and have it less severely. 5. The period of incubation is from one to five days. 6. One attack is protective, as a rule. Morbid Anatomy.— 1. The blood is dark in color and does not coagulate readily. 2. The heart, kidneys, spleen and liver undergo degenerative changes as in the other infectious diseases. The liver in yellow fe- ver, however, is of a yellow color, and its cells are filled with fat. 3. Infarctions of the lungs are of frequent occurrence. 4. The mucous membrane of the stomach and bowels is greatly congested. 5. The skin in most cases is of a deep yellow color, and the con- junctivae are similar in appearance. Symptoms.—1. Nervous; chilly sensations, sometimes chills, headache, pain in the back and limbs and tenderness over the stomach are the most important and common nervous symptoms. In severe cases delirium occurs and may be very troublesome. 2. The temperature ranges from 1020 to 105°, and rises rapidly to this point. There is usually a remission on the fourth or fifth day and in mild cases this is the beginning of convalescence. 3. The circulatory symptoms are, quickening of the pulse and weakness of the heart's action. The pulse is, however, slower in yellow fever than in the other acute infectious diseases, and this fact is apparently connected with the jaundiced color of the skin. 4. The digestive symptoms are nausea and vomiting, and usually constipation. The vomited matters are in mild cases very bilious in character, and in some cases contain blood, constituting the dreaded black vomit. 5. The urinary symptoms are scantiness and in some cases sup- pression of urine. There is sometimes albuminuria. 6. The skin is* usually of a yellow color and prespiration is common. Diagnosis.—The diagnosis is based on—1. The black vomit. 2. The range of temperature. 3 The color of the skin. 4. The suppression of urine. The Prognosis is always very serious, but differs in different epidemics. The mortality ranges from 10 to 30 per cent. PRACTICE OF MEDICINE. 57 The Duration is usually about six days, but convalescence is often tedious. Treatment.—The prophylactic treatment consists in—i. Quar- antine. 2. Disinfection of clothing, &c. The remedial treatment.—Diaphoretics have been found useful. They probably act by lessening the work of the kidneys. Restlessness and nausea should be relieved by morphia and champagne or brandy. Malarial Diseases. Definition.—Affections differing very much in character, but all of which are due to a poison generated in warm and damp lo- calities, especially in marshy places. Causes.—I. A germ is the essential cause; probably that described by Laveran ; it may occur in several different forms. Sometimes it is found in a red blood corpuscle, when it is amoeba likein character, capable of slow movement, and causes destruc- tion of the corpuscle with liberation of pigment; there may be but one germ in a corpuscle, or there may be several. Sometimes these germs contain pigment which is arranged in the form of a rosette. Crescent-shaped germs, with clubbed ends, are found free in the blood, and now and then oval, or round, or pear-shaped parasites, with flagellae. 2. The favorable conditions for the development of these germs are warmth and moisture. Marshy ground, which is sometimes covered with water and sometimes exposed to the sun, is an espe- cially favorable soil for their development. The conditions which render a person liable to malarial attacks are debility from any cause and a previous attack. 3. The avenues of introduction of the germs are the respiratory mucous membrane and the intestinal canal. 4. The media of conveyance are— (1) atmospheric air; the germs are sometimes carried consid- erable distances by currents of wind, but they are contained in the lower strata of the atmosphere, and hence persons on high land or in the upper story of a house are not so liable to take the disease as those at a lower level; (2) waters from malarial districts may carry the germ for long distances; (3) milk is probably also a medium of conveyance; (4) possibly certain articles of diet may act as media of con- veyance. 5. One attack does not confer immunity from subsequent ones, 8 53 PRACTICE OF MEDICINE. but, on the contrary, increases the liability to them. 6. The period of incubation is not fixed ; it probably varies from five to thirty days. There is sometimes apparent tolerance of the malarial poison when persons living in a malarial country do not suffer from mala- rial affections, but the course of any disease occurring in such per- sons is usually modified by the malaria. Latency is said to exist when there is no evidence of malarial poisoning for some time after exposure, but when subsequent de- velopments prove its existence. Forms of Malarial Diseases—The following forms are com- paratively common : i. Intermittent fever. 2. Remittent fever. 3. Typho-malarial fever. 4. Chronic malarial toxaemia. 5. Pernicious malarial fever. Intermittent Fever. Definition.—An acute infectious disease due to the presence of the malarial germ and characterized by periodical recurrences of chills, fever and sweating, the person being free from fever in the interval. Synonyms.—Ague and fever. The shakes, and chills and fever, &c. Causes.—The causes are those of malarial affections generally. Types.—1. Quotidian. 2. Tertian. 3. Quartan. 4. Double forms. 5. Dumb ague and masked forms. 6. Those in which there is a tendency to recurrence every seven, or fourteen, or twenty-one days. Symptoms During a Paroxysm.—1st, or cold stage, lasts about one or two hours— (1) the skin is cool and covered with "goose-bumps" ; (2) the internal temperature is increased, while that of the surface and extremities is depressed ; (3) the nervous symptoms are a chill and pain in the head, back and limbs, and a feeling of extreme coldness ; (4) the digestive symptoms, nausea and vomiting are common. The 2nd, or hot stage, lasts five or six hours usually— (1) the skin during this stage becomes red and hot; PRACTICE OF MEDICINE. 59 (2) the temperature is elevated to 1040 or 105 ° or even to 1060 or 1070 ; (3) the pain in the head and back and limbs is intense. 4. The circulatory symptoms are fullness and quickness of the pulse, which often reaches 1 io° or 1200. 5. The digestive symptoms are nausea and vomiting. In the third, or szveating stage, there is a profuse sweat and relief to the pain in head and limbs. " Dumb ague" is said to occur when there is fever and possibly sweating without a chill. In the masked forms the paroxysm of chill and fever may be replaced by some other disturbance, such as neuralgia. Symptoms in the interval between the paroxysms are not marked, but there is usually some sallowness of the skin and more or less enlargement of the spleen. Diagnosis.—1. From remittent fever intermittent is diagnosed by the occurrence of complete intermissions in the latter. 2. From pyaemia it is diagnosed by the history of the case and by the serious condition of the patient between the paroxysms in pyaemia. Prognosis.—The prognosis is nearly always favorable. If the chills occur at an earlier hour at each recurrence they are said to be " anticipating," and it is not a good indication; if they come at a later hour at each recurrence they are said to be "postponing," and it is a favorable sign. Treatment. — General prophylaxis. Drainage and cultivation do more than any thing else to remove the favorable conditions for the development of the malarial germs. Individual prophylaxis may be practiced by the administration of from two to five grains of quinine every morning before break- fast. During the cold stage of a paroxysm morphia and chloroform to quiet the nervous system are often useful. At the beginning of the hot stage antipyrine or antifebrine or phenacetine may be given to lower the temperature and hasten the occurrence of sweating. Pilocarpine has been used for the same purpose. During the szveating stage no treatment is necessary. In the interval between the paroxysm, quinine in full doses should be used. Opium increases its effect. Salicin, arsenic and nitric acid are also useful. The bowels should be opened by calomel. In chronic cases, iron and cod liver oil are very beneficial. 6o PRACTICE OF MEDICINE. Remittent Fever. Definition.—A malarial fever characterized by remissions, but not complete intermissions. Symptoms.—Bilious fever; bilious remittent fever, &c. Special Causes of this form of malarial disease—I. I Feat; the severity of the malarial diseases usually increases with the tempera- ture of the locality. 2. Inflammatory complications, which tend to make an ordinary intermittent fever assume a remittent type. Morbid Anatomy.— i. The blood contains much free pigment from the destruction of the red corpuscles by the germs. 2. The spleen is enlarged from the action of the germs and the toxic principles formed by them. 3. The liver is congested and contains pigment. 4. The stomach and bozvels are usually congested. Symptoms.— 1. Digestive, oppression in the epigastrium, nau- sea and vomiting; the tongue is at first pasty, later brown and dry; the bowels constipated at first, but often become loose after- wards. These symptoms arc probably due to the action of the toxic principles formed. 2. The nervous symptoms consist of a chill, headache, back- ache and pain in the limbs, with extreme restlessness. The chill is not so violent as in intermittent fever. Delirium occurs later on. 3. The temperature rapidly rises to 1050 or 1060, but after about twelve hours it falls two or three, or even four degrees; this is called the remission. As the disease advances the remissions which occur in the beginning at regular intervals become less and less marked. 4. The circulatory symptoms. The pulse is at first full and ra- pid, in consequence of the action of the heated blood on the mus- cular tissue of the heart and the nerves ; later it becomes rapid and weak from degenerative changes. 5. The general symptoms are exhaustion and emaciation. Bilious remittent fever is that form in which there is jaundice and large quantities of bile are vomited. Diagnosis.—1. Typhoid fever differs from remittent fever in the gradual rise of temperature, and the early occurrence of diarrhoa in the former, and also in the more continued course of the fever. 2. Yellerw fever differs from remittent fever in the occurrence of black vomit, and the much greater degree of jaundice in the former. Prognosis.—The prognosis depends on— L. The type of the epidemic. practice of medicine. 61 2. The locality, the disease being more fatal in hot and marshy places. 3. The complications. Duration.—There is no definite duration; the average length of an attack is about two weeks. Treatment.—The Fiygienic treatment with respect to food stimu- lants and general regimen is like that of typhoid fever. The indications in remedial treatment are—1. To relieve symp- toms as— (i.) Nausea by counter-irritants, morphia, chloroform, &c. (2.) Constipation by calomel and enemata. 2. To reduce temperature by antipyretics. 3. To destroy the germs or neutralize the poison generated by them by quinine. Typho-Malarial Fever. Definition.—A febrile affection characterized by a combination of the symptoms and morbid anatomy of typhoid fever and mala- rial affections, each being modified by the other. In its essential nature it is probably typhoid fever occurring in a person whose sys- tem is charged with the malarial poison. Symptoms —Camp fever, malarial typhoid fever, continued ma- larial fever, &c. Causes.— 1. The germ of typhoid fever is probably the essen- tial cause of typho-malarial fever, but it has not yet been found in the disease. Themalarial germ is present in these cases also. 2. The favorable conditions for development are defective sewerage and defective drainage; in a word, moisture and filth. It is unnecessary to say more as to the causes, which are the same as those of typhoid fever and malarial affections combined. Morbid Anatomy.— 1. The blood is dark in color and coagulates badly. 2. Parenc/iymatous* degeneration occurs in the heart, liver, kid- neys and muscular tissue. The spleen is mueh enlarged. The explanation of these changes has been given in connection with ty- phoid fever. 3. The intestines are inflamed, especially in the neighborhood of the ileo-ccecal valve. Peyer's patches are enlarged and ulcerated, just as in typhoid fever, but the changes do not occur with the same regularity and order as in pure typhoid fever. 62 PRACTICE OF MEDICINE. Complications.—Inhalation pneumonia, bronchitis, and laryn- geal inflammations, as in pure typhoid fever. Similar glandular and intestinal complications also occur. Symptoms.— I. Nervous. A chill is common at the beginning of typho-malarial fever; headache and pain in the back and limbs occur just as in typhoid, and low muttering delirium, subsultus ten- dinum and other nervous symptoms occur in the later stages. 2. The temperature curve in malarial fever is different from that of pure typhoid. Instead of the gradual rise which is usual in the latter, the temperature often reaches i04°or 1050 within forty-eight hours from the commencement of typho-malarial fever. There are frequently much more marked remissions also in this disease than in simple typhoid. The other symptoms are practically similar to those of uncomplicated typhoid fever and need not be repeated here. Diagnosis.— 1. From simple typhoid fever typho-malarial is distinguished by the much more rapid elevation of temperature, by the occurrence of remissions, and by the chill which often occurs at the commencement of the attack. 2. From remittent fever it is distinguished by the occurrence of diarrhoea and sometimes of the typhoid eruption. Prognosis.—The mortality varies in different epidemics; it is usually about eight or ten per cent. The prognosis is dependent on — 1. The type of the epidemic. 2. Bad hygienic surroundings and intemperate habits in the pa- tient, which increases the mortality very much. 3. Complications. Treatment.—The prophylactic treatment is the same as that of typhoid fever. The disinfection of the stools and bedding is es- pecially important. The indications of remedial treatment are—1. To reduce tem- perature; which may be accomplished by antipyrites, such as phe- nacetine, antipyrine, &c, and quinine, which is much more useful in this disease than in pure typhoid fever. 2. To sustain strength by the use of food and stimulants. 3. To relieve symptoms, such as nausea and vomiting, diarrhoea, headache, &c. The nausea is best relieved by small doses of mor- phine and codeine in conjunction with chloroform ; these drugs les- sen the irritability ot the stomach. Diarrruea is controlled by opium, bismuth, naphthaline and other astringents and antiseptics. Phenacetine and codeine give prompt relief to the headache and pain in the limbs. 4. Specific treatment directed to the malarial element is useful in those cases which are marked by decided remissions or in which there are other prominent features of malarial poisoning. PRACTICE OF MEDICINE. ^ Pernicious Malarial Fever. Definition.—Malarial affections so severe in character as to oc- casion death or very great danger. Synonym.—Congestive chills. Causes.— I. The malarial poison, as in other forms of malaria, is the essential cause. 2. Heat. The pernicious malarial fevers are very rare except in hot countries or in very hot weather. 3. Certain uukuozou conditions are also operative, for in the same locality pernicious malarial affections are much more common in some seasons than in others. Morbid Anatomy.—The spleen and other internal organs show extreme congestion, pigmentation and sometimes infarctions. The Varieties and Symptoms in each. —1. The comatose, in which during the hot stage the person becomes very drowsy and may sink into profound coma. The pulse in this form is full and strong and slow and the res- pirations slow, the face flushed and pupils small. The temperature often reaches 105° or even 1070. 2. The delirious form is characterized by wild delirium in the hot stage. The pulse is rapid and the respiration hurried. 3. In the gastro-enteric form there is profuse vomiting and purg- ing. The pulse is rapid and feeble, and the extremities are cold. There is sometimes complete suppression of urine, and it is always scanty. 4. In the algid form, the cold stage persists, and the extremities become very cold, though the internal temperature is elevated. The pulse is rapid and feeble, and in bad cases disappears from the wrist. 5. The icteric form is characterized by the occurrence of jaundice, which comes on quite suddenly, usually in the hot stage; the pulse is often unusually slow in this form, and stupor and muttering de- lirum are common. In the hemorrhagic form there is apt to be hemorrhage into the serous cavities and into the internal organs, especially the kid- neys. The symptoms are very variable, depending on the seat and amount of the hemorrhage. It should be remembered that malarial hematuria is not always pernicious in character. It is not possible to explain the causes of these different forms. The icteric form is probably due to a very great destruction of the red blood corpuscles ; the hemorrhagic to profound changes in the walls of the blood vessels. 64 PRACTICE OF MEDICINE. Diagnosis.— I The comatose form is distinguished from apo- plexy by the fever and the absence of hemiplegia, and by its gradual onset. 2. The delirious form is distinguished from meningitis by trie chill which precedes it, and by the more rapid rise of temperature. Prognosis.—The prognosis is usually unfavorable. It is based on the form—the algid, icteric and gastro-enteric being the most fatal—and on the locality—all cases being worse in a hot and marshy local ity. Treatment.—During a. paroxysm morphia and chloroform are very useful; antipyrine and pilocarpine have also been used with benefit in the comatose and delirious forms, and also in the algid. In the interval, and sometimes even during a paroxysm, quinine should be given hypodermically, in doses of about three grains every two or three hours. Chronic Malarial Tox/emia. Causes.—Chronic malarial toxaemia may occur: I. In those persons who have long been residents of a malarial region, but who have never had any acute manifestations of the disease. 2. As a sequel of the acute attacks. Morbid Anatomy.—The morbid anatomy is similar to that of the acute attacks except that it is greater in degree. The spleen is more enlarged, the liver and kidneys are apt to present evidences of degeneration. The heart is usually softened and is flabby. Symptoms.—The symptoms vary very greatly in different eases, i. The most common nervous symptoms are neuralgia in different parts of the body, headache, sleeplessness, depression of spirits and occasionally actual melancholy. Paralysis occurs occa- sionally. 2. The digestive symptoms are very variable. Sometimes diar- rhoea occurs, the actions being light colored and pasty. Some- times on the contrary there is constipation. The appetite is nearly always impaired. Tenderness over the liver and spleen is usually observed. 3. The respiratory symptoms are "shortness of breath," which is due to the diminution in the number of red corpuscles, and some- times bronchitis and cough. 4 The circulatory symptoms are weakness of the heart's action and palpitation, both of which are due to defective nutrition. 5. The general symptoms are pallor, from destruction of red cor- puscles, debility from degeneration of the heart and muscular tissue, and very often dropsy from weakness of the heart and degenerative changes in the vascular walls. practice of medicine. 65 Diagnosis.—The diagnosis is based on—1. The enlarged spleen. 2. The remissions which usually occur. 3. The presence of pigment m the blood. 4. The effect of specific treatment with quinine. Prognosis.—The prognosis depends on the morbid changes and symptoms. If the spleen is greatly enlarged and tender, and there is tenderness and enlargement of the liver, and dropsy, it is unfavora- ble. Treatment.—The treatment consists in change of residence, the wearing of flannel to promote the action of the skin, and the admin- istration of quinine, iron, cod-liver oil and arsenic. Warburg's tincture often gives better results than anything else. Mumps. (Parotitis.) Definition and Frequency.—An acute, infectious and conta- gious disease characterized by swelling of the parotid glands. It is an exceedingly common affection. Causes.— 1. A germ which has not been isolated. 2. Age. It is far more common in children than in adults, but may occur at any age. Young infants usually escape. 3. The avenue of introduction is probably the respiratory mu- cous membrane. 4. The medium of contagion, the atmosphere, in most cases if not in all. 5. Immunity is usually conferred by one attack. 6. The period of incubation is from 12 to 21 days. Morbid Anatomy.—The parotid glands—one or both—are hy- perasmic and infiltrated with serum. Symptoms—A. Prodromic symptoms, such as malaise, slight fever and headache, are frequent. B. Symptoms of developed attack. 1. Glandular. One or both parotid glands become swollen, tender and painful. The swelling has no tendency to suppurate. 2. The temperature is elevated to 1020 or 1030 generally, but may rise to 1060. 3. The pulse is quickened and appetite lost. Diagnosis.—The diagnosis is based on the swelling of the caro- tid, without pyaemic symptoms. Prognosis.—The prognosis is nearly always favorable. 66 practice of medicine. Complications.— i. Glandular. The testicles in males, or the breasts or ovaries in women, may become greatly inflamed and ten- der. 2. Serious cerebral symptoms, violent headache, stupor or deli- rium may occur, but usually pass off in a few days or, possibly, a few hours. Treatment.— Treatment isjof little'value. The indications are to give relief from pain and to lessen the severity of complications. Rubbing with camphorated oil is the best external treatment. The bromides and phenacetine may.be given in case cerebral symp- toms arise. practice of medicine. 67 CrfAPTER III. DISEASES OF THE RESPIRATORY ORGANS. ACLTE CORYZA. Definition.—An acute catarrhal inflammation of the mucous membrane of the nose. Synonyms.—Acute nasal catarrh, cold in the head, &c. Causes. — 1. Sudden chilling of the body when overheated ; the way in which this acts is obscure. 2. Injuries, whether mechanical, as cuts or blows, or inspissated mucous ; or chemical, as from the inhalation of certain irritating va- pors or from* the elimination of certain drugs taken internally, such as iodine. 3. The exantliemata, especially measles. Morbid Anatomy.—1. Redness and swelling of the mucous membrane and a catarrhal exudate. There is also distension of the erectile tissue over the turbinated bones. Symptoms.—1. Nervous. Sometimes there is a chill or chilly sensations, some headache, a feeling of dullness and some- times pain in the back and limbs. Sneezing almost always occurs from the increased reflex irrita- bility of the nerves of the nasal mucous membrane. 2. Secretory. At first there is a thin secretion, from the stimula- tion of the mucous follicles by the increased flow of blood; later on a catarrhal exudate. 3. Mechanical. There is stopping up of the nose, and so-called nasal speech from the swelling of the mucous membrane over the turbinated bones. Prognosis.—Recovery nearly always occurs in a few days. Rarely chronic coryza results. In the case of infants, the interference with sucking may cause debility and even death. Treatment.—The first indication is to increase the amount of blood in the skin and in that way cause a collateral anaemia of the nasal mucous membrane. For this purpose warm baths, hot drinks, quinine, Dover's powders, jaborandi and antipyrine may be used with great advantage. The local treatment consists in inhalation of tincture of iodine and ammonia, a spray of borax and bicarbonate of sodium, and the 68 PRACTICE of medicine. use of a snuff of cocaine, antipyrine, boracic acid and bismuth. These agents seem to destroy the germs which lodge in the nasal mucous membrane and help to keep up the inflammation. Anti- pyrine also causes contraction of the blood vessels and cocaine re- lieves pain. Chronic Nasai. Catarrh. Definition.—A chronic catarrhal inflammation of the nasal mu- cous membrane. Synonyms.—Catarrh, ozaena. Causes.—i. Acute coryza. 2. Atmospheric condition, such as dampness and the presence of irritating vapors, such as tobacco smoke and the fumes generated in certain manufacturing operations. 3. Syphilis, tuberculosis and scrofula. These are very common causes of chronic nasal catarrh. Morbid Anatomy of—1. Hypertrophic form. There is swell- ing and redness of the mucous membrane and hypertrophy of the tissues over the turbinated bones. 2. Atrophic form. In this form there is atrophy of the mucous membrane and the tissues beneath. The mucous follicles are de- stroyed and even the bony tissue is thinner than natural. Symptoms.— 1. Secretory. There is, in the hypertrophic form especially, a more or less copious secretion of yellowish or greenish muco-pus, which frequently dries and forms crusts in the nose. The discharge is often offensive from the decomposition set up by germs. 2. Respiratory. In the hypertrophic form there is often some obstruction to nasal respiration ; in the atrophic form, on the other hand, the air passes through the nose very easily. Physical Signs.—On examination with the rhinoscope the tis- sues may be seen thickened and red in the hypertrophic form, or pale and dry and atrophied in the atrophic form. Diagnosis.—The diagnosis is no'; difficult. It is important to look for the evidences of scrofula or tubercle or syphilis, to deter- mine whether these conditions cause the catarrh. Prognosis.—The prognosis as to life is good ; as to recovery it is not very good, unless the disease is slight and is due to syphilis. Treatment. —1. General. To improve the general Fiealth by tonics, &c. To reside in a dry country is of more importance than anything else. To treat syphilis when present. PRACTICE of medicine. r9 2. Local. To remove crusts by sprays containing bicarbonate of soda and by the application of vaseline to soften them. To lessen fetor by carbolic acid or permanganate of potash solu- tions used with an atomizer. To remove hypertrophic tissue by caustics or the knife. The galvano-cautery is very useful, for it prevents hemorrhage. Nose Bleed or Epistaxis. Causes.— i. Injuries which cause rupture of the vessels. 2. Hemorrluxgic diathesis. 3. Certain forms of heart disease in which the vascular walls are weakened and the heart's impulse is increased. 4. Purpura, leukaemia, &c , in which' there are changes in the blood and disease of the walls of the vessels also. Treatment.— 1. Quiet, to allow a coagulum to form in the in- jured vessel. 2. Antipyrine, which causes contraction of the blood vessels. It should be used as an injection into the nose or as a snuff. 3. Mouse!s Solution.—The nose may be plugged with absorbent cotton soaked in dilute Monsel's Solution. 4. Plugging of the anterior nares and of the posterior nares by means of Bellocq's cannula. 5. Ergot is sometimes given internally, but it is of doubtful value. Acute Catarrhal Laryingitis. Causes.—1. Constitutional predisposition has an evident influence in causing acute laryngeal catarrh, some persons being far more lia- ble to it than others. 2. Chilling of the body when overheated. 3. Mechanical or chemical irritants, as from the inhalation of irritating powders or vapors. 4. It occurs also in measles and other of the acute exantliemata, typhus, &c. Morbid Anatomy.—1 Redness and some swelling. 2. Exudation, which is small in quantity and serous in character at first; later becoming sero-purulent. 3. Infiltration of the sub-mucous tissue with serum occurs in se- vere cases. Symptoms.— 1. The voice is affected, there being more or less hoarseness, or in severe cases complete aphonia. 2. Respiration is not affected unless there is sub-mucous inflltra- 70 practice of medicine. tion, when it is seriously interfered with. Cough of a ringing and spasmodic character is often present from the increased reflex irrita- bility. 3. Pain is rarely present, but there may be a slight feeling of soreness. 4. The secretion is slight because the laryngeal mucous mem- brane contains few mucous glands. Physical Signs.—On laryngoscopy examination the vocal cords are observed to be reddened ; there is some mucopurulent secre- tion on them, and the movements of the muscles are impaired. False Croup, which occurs in children, is due to a reflex spasm of the larynx. The acute laryngitis increases the irritability of the sensory nerves, and this causes reflex spasm of the larynx. The symptoms of false croup are a ringing cough, from the vi- bration of the tense vocal cords, and dyspnoea, from the spasmodic narrowing of the wind-pipe. Diagnosis.—From [diphtheria acute'laryngitis is diagnosed by the absence of any false membrane in the latter. From hysterical laryngeal spasm, by the suddenness of the on- set of hysterical attacks, and by the absence of evidences of in- flammation. Prognosis.—The prognosis is usually very favorable. It is sometimes serious in young children, and there is especial danger in them of extension to the bronchi. When due to the inhalation of irritating vapors, such as steam, it may cause death from oedema. Treatment.—1. To lessen congestion by dilating the vessels of the skin, is the first indication. 2. To promote secretion by the use of steam'inhalations, to which compound tincture of benzoin may be added. 3. To facilitate the entrance of air, when oedema is present, by means of scarification or tracheotomy. Chronic Laryngitis. Definition.—Chronic catarrhal inflammation of the larynx. Causes.— 1. An acute attack. 2. Occupation ; persons who do much public speaking are es- pecially liable to it; hence it is sometimes called .clergyman's sore throat; singers are also apt to suffer from the disease. Persons who work where there are irritating vapors or fumes are liable to it. 3. Dissipation is a very potent cause, it being especially common among drunkards. practice of medicine. 71 Morbid Anatomy.— 1, Redness, szv tiling and sometimes ulcera- tion of the mucous membrane of the larynx. Irregular swelling and contraction are caused by the formation of connective tissue in the mucous and sub-mucous tissue. Symptoms.— 1. The voice is affected to a greater less degree. Hoarseness is nearly always present, and even when it is not appa- rent in ordinary conversation, it is impossible to strike the high notes in singing. 2. The respiration is not affected, as a general thing. There is some expectoration of tough mucus of a yellowish color, usually, but the amount expectorated is small. The nervous symptoms are cough, which is not often trouble- some, and a feeling of weakness and soreness of the throat, rather than of actual pain. Physical Signs.—On laryngoscopic examination the vocal cords present the appearances mentioned under Morbid Anatomy. Diagnosis.—The diagnosis is based on the history of the case and the results of the laryngoscopic examination. It has to be distinguished especially from tuberculosis and syphilitic laryngitis, or tumors of the larynx. Prognosis.—The prognosis as to life is very good ; as to recov- ery, it must be guarded ; it will depend very much on the climatic and hygienic conditions. Treatment.—A. Hygienic. Rest to the voice, the avoidance of irritants, such as smoking, drinking, &c. A warm and equable climate are of the utmost importance. B. Remedial treatment consists in T. Inhalations of weak solutions of tannic acid, alum, boracic acid, &c. 2. Applications to the larynx, with the brush, of solutions of nitrate of silver, carbolic acid, iodoform, &c. 3. The insufflation of powder, such as boracic acid, iodoform, bismuth, sulphur, &c. 4. Constitutional treatment with the object of causing a collat- eral hyneraemia of the abdominal organs and a consequent anaemia of the organs in the thorax. The sulphur waters, and others which act on the bowels, have been found of service. Laryngeal Perichondritis. Definition.—An acute inflammation of the peri-chondrium, Causes. — 1. Tuberculosis, sypFiilis, cancer, &c. 72 PRACTICE OF MEDICINE. 2. Rarely the acute infectious diseases, especially small-pox and typhus. Morbid Anatomy. — i. Seat in the cartilages of the larynx. 2. The exudate is purulent and collects between the perichon- drium and the cartilage. 3. The cartilage is destroyed and discharged with the pus. Symptoms and Signs.—Those of stenosis from swelling of the larynx and consequent narrowing of its calibre. Pain is also pres- ent and is often severe. Diagnosis is made by the history of the case and laryngoscopic signs. Prognosis is bad. If recovery occurs there is apt to be perma- nent narrowing of the larynx. Treatment. — Tracheotomy, to admit air, and then the removal of pus from the abscess. CEdema of the Glottis. Definition.—Infiltration of the sub-mucous tissue of the larynx with serous fluid. Causes. — 1. Acute laryngitis. 2. Perichondritis. 3. Dropsy, from heart disease or Bright's. Symptoms.—Dyspnoea is the prominent and essential symptom. Treatment.— 1. Incisions, to let out the fluid. 2. Tracheotomy, to permit the entrance of air. Spasm ok the Glottis. Causes. —1. Age and sex, most common in boys under three years old. 2. Rickets predisposes to it: the reason is not known. Symptoms.— 1. Sudden dyspnoea, from closure of the glottis. 2. Convulsions sometimes, from retention of carbon dioxide in the blood. Prognosis.—Usually good so far as the attack itself is con- cerned. Treatment.—1. To improve the general health, 2. Chloroform during paroxysm. PRACTICE OF MEDICINE. 73 TUBECULOSIS OF THE LARYNX. Causes.— I. The bacillis tuberculosis is the essential cause. 2. It may be primary, but is usually secondary to tuberculosis of the lungs. Morbid Anatomy.— i. Redness of the cords with little whitish elevations (tubercle.) 2. Later on, ulceration of the cord, the ulcers being caseous and showing no disposition to heal. Symptoms.— i. Hoarseness or complete aphonia. 2. Cough, often troublesome. 3. Difficult and painful deglutition from ulceration and irritabil- ity of the epiglottis. 4. Weakness, pallor, night sweats, &c, as in tuberculosis of other organs. Diagnosis based on— i. The presence of tuberculosis elsewhere. 2. The character of the ulcers. Prognosis.—Uniformly unfavorable. Treatment.—I. To improve the general health and sustain strength. 2. To apply germicides, such as iodoform, to the ulcers. This treatment is of very doubtful efficacy. 3. To facilitate deglutition. The use of a spray of cocaine (10 per cent.) just before eating gives very great relief. Syphilis of the Larynx. Period of Occurrence—Secondary. Morbid Anatomy.— i. Redness and szvelling, usually in patches. 2. Ulceration, the ulcers being inclined to heal on one side and extend on another. Symptoms—I. The voice is seriously affected; hoarseness is nearly always present and there may be complete aphonia. 2. Deglutition is painful and difficult. 3. Cough is present, and in late stages more or less dyspnoea is common from cicatricial contraction. Diagnosis based on—i. The history of the case. 2. The character of the ulcers. Prognosis.—Favorable in the early stages; later, stenosis is apt to occur. Treatment.—The iodides in large doses and mercury. 74 practice of medicine. Paralysis of the Laryngeal Muscles. Causes.— i. Central, as degeneration of the nerve centres in bulbar paralysis. 2. Peripheral, from pressure on the nerve trunks by tumors or degeneration of the nerves, as in diphtheria. 3. Changes in the muscles themselves, as in certain degenerations. 4. Functional, as in hysteria. Symptoms.— 1. The voice is always-affected and often there is complete aphonia. f 2. Respiration may be interfered with, but it is usually unaf fected. Diagnosis.—The diagnosis is based on the history of the case, and the results of a laryngoscopic examination. Prognosis.—The prognosis depends altogether upon the cause. If the pressure can be removed from the nerve, for instance, it is favorable. In hysterical cases it is favorable. Treatment.—1. To remove the cause. 2. To stimulate the nerves by electricity, strychnia and other tonics. Physical Diagnosis of Affections of the Respiratory Organs. Divisions of the Chest.—A. Anterior.— 1. Supra-clavicular, above the clavicle. 2. Infna-clavicular, from the clavicle to the third rib. 3. Mammary, from the third to the seventh rib. 4. Infra-mammary, from the 7th rib to the edge of the thorax. B. Lateral.— 1. Axillary, from the arm pit to a line connecting the lower angle of the scapula with the lower border of the infra- clavicular region. 2. Sub-axillary, from the axillary to the twelfth rib. C. Posterior.— 1. Supra-scapular, above the spine of the scapula. 2. Scapular, underneath the scapula. 3. Infra-scapular, from the lower angle of the scapula to the twelfth rib. 4. Inter-scapula, between the scapulae. Methods of Physical Diagnosis. — 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. Inspection.— Method* The patient must be stripped t o the wai>t The physician shouk1'stand in front of the person or direct- PRACTICE of medicine. 75 ly behind him. The person to be examined should stand erect with the arms falling loosely at the sides. Objects of Inspection. To determine (i) the size of the chest, (2) the shape of the chest, (3) the movements of the chest, (4) the rela- tive size and movements of the two sides. Changes in Disease.—The size of the chest may be greater than normal from an excessive amount of air in the air cells (em- physema,) from muscular development, and possibly from dropsy. The shape of the chest is altered in certain diseases, as emphy- sema, when it is barrel-shaped, and as a result pf pleurisy with effu- sion on one side or with retraction of the chest walls from adhesions and shrinking of the lung. The movements of the chest are very frequently changed by dis- ease. If respiration causes pain on one side, as in pleurisy, or pleu- rodynia, the movements on that side are less extensive than nor- mal. If there is effusion into the pleural sack, the movements are greatly lessened or are absent. Palpation.—Method.—To practice palpation the hands should be placed upon the chest walls. Objects. The objects of palpation are to determine the size, shape and movements of the chest and also the character of the vocal frem- tus and in certain diseased conditions the rhoncalfremitus also. The vocal fremitus is the peculiar thrill imparted to the hand placed upon the chest of a person who is talking. Its degree depends upon (1) the thickness of the chest walls —thick walls lessen the fremitus—and (2) the pitch of the voice; it is greater when the voice is low in pitch than when it is high. Changes in Disease.—The vocal fremitus maybe (1) increased or (2) diminished or lost in diseased conditions. It is increased whenever the lung tissue is solidified, as in pneumonia or tubercu- lar consolidation. It is diminished or lost (1) when there is a layer of fluid between the lung and the chest wall, as in pleurisy with effusion; (2) when the bronchus leading to the portion of lung under the examining hand is stopped up. Rlioncal fremitus is never present in health. It is due to the vibration occasioned by narrowing of the bronchial tubes or by the presence of mucus in the tubes. Percussion Methods.—There have been two methods of per- cussion practiced—(i) the immediate, in which the chest is struck directly, and (2) the mediate, in which some other body, usually the fingers of one hand, are placed on the chest and struck with the percussing fingers. A little hammer and a piece of rubber or ivory may be used in place of the fingers. The mediate method is nearly always adopted now. Object.—The object of percussion is to determine the relative 76 practice of medicine. amounts of air and solid or liquid matter in the lung or chest cav- ity. The sounds elicited on percussion are to be considered with re- spect to (i) quality, (2) pitch, (3) duration, (4) intensity. The percussion sounds in different regiotis of the chest depend in the healthy person upon (1) the difference in thickness of the thoracic walls in different persons and at different parts of the chest, and (2) upon the character of the underlying tissues or or- gans. The percussion sounds are clearer in the axillary and sub-clav- icular regions, as a rule, than elsewhere, because the chest walls are thinner there. There is more resonance in the left sub-clavic- ular region than in the right, because the large bronchus on the right side lessens the amount of pulmonary tissue. There is ab- sence, or great diminution, of resonance over the region of the heart, and also below the sixth rib on the right side, because the liver lies beneath. Changes in the percussion sounds produced by disease.— 1. Flat- ness, or an absence of all resonance is nearly always due to an accu- mulation of fluid in the pleural cavity, or a tumor there. 2. Dullness, or a diminution of resonance is due to a relative 01 actual diminution in the quantity of air in the lung. It is conse- quently observed in pneumonia, tubercular infiltration, and in any other condition in which the amount of air is lessened. 3. Tympanitic resonance is due to an actual or relative increase in the amount of air in the lungs, as in emphysema, and in certain cases where there is a cavity in the lungs. 3. Amphoric resonance is characterized by its metallic character; it is obtained by percussing over cavities with firm, elastic walls. 5. The cracked-metal sound is produced by percussing over cavities which communicate with a bronchus by a small opening. Auscultation.—Methods. By auscultation is meant the listening to the sounds in the chest. There are two methods, (1) the imme- diate when the ear is applied directly to the chest walls, and (2) the mediate when a stethoscope is employed. Sounds over the healthy chest. The respiratory or vesicular murmur is the sound produced by the entrance of air into the air vesicles. The thinner the chest walls and the deeper the inspirations the louder the vesicular murmur is. Its intensity or loudness varies greatly in different persons. It is heard most distinctly in the sub-clavicular and axillary regions, be- cause the chest walls are thinner there. Over the upper part of the sternum and in some children under- neath the right clavicle and between the upper ends of the scapulae a sound is heard like blowing through a tube. This is known as J practice of medicine. 77 bronchial or tubular breathing and is owing to the proximity of the large tubes to the walls of the chest at these points. The vesicular murmur is heard during inspiration. The expira- tory sound is much shorter than the inspiratory and rather more blowing in character. Inspiration is due to the action of the pow- erful muscles; expiration is due chiefly to the elasticity of the lungs. Changes in the vesicular murmur in disease. Alterations in intensity, i. Increasedor puerile respiration is usu- ally compensatory; for example, if one lung is solidified or com- pressed the sounds over the other lung are increased. 2. Diminished or feeble respiration may be due (i) to some ob- struction ,to the entrance of air into the lungs as the plugging of a bronchus or weakness of the z'/zspiratory muscles, or (2) to some hin- drance to the transmission of sound to the ear such as a thin layer of fluid in the plueral cavity, or (3) to a loss of elasticity of the air cells which prevents the discharge of air from the air cells prior to their refilling with air. 3. Absence ofrespiratory sound'is due to the complete plugging of a bronchus or to a thick layer of fluid between the lungs and chest walls. Alterations in rhythm.— 1. Jerky respiration is due to irregular di- latation of the tubes and air cells; it has little clinical significance 2. Change in the relative length of inspiration and expiration is of great practical importance. Prolonged expiration is an evidence of a loss of elasticity of the walls of the air vesicles, and this loss of elasticity may be occasioned by over-distension of the air cells as in emphysema or deposits which impair their contractile power as tubercle. Alteration in character. Harsh, broncho-vesicular, respiration is a mixture of the vesicular murmur with bronchial respiration. It shows a diminition in the relative amount of air. When heard at the apex of the lung it is very suggestive of tuberculosis. Bronchial Respiration is heard in health over the upper part of the sternum and in some persons, especially children, under the right clavicle and between the spines of the scapulae, because large tubes are in close proximity to the chest walls at these points. Bronchial respiration, or tubular respiration, if heard elsewhere is an evidence of consolidation of the lung tissue beneath. It is ob- served, therefore, in pneumonia, tubercular infiltration and collapse of the lung. Bronchial respiration may be absent over consolidated lung tis- sue, however, (1) if the bronchus leading to the consolidated lung is stopped up, (2) if there is a layer of fluid between the lung and the chest walls, as in pleurisy with effusion, or (3) if the consolidated lung is central and surrounded by healthy tissue. 78 PRACTICE OF MEDICINE. Amphoric Respiration resembles the sound produced by blowing over the mouth of a bottle. It is heard over cavities with tense, elastic walls and is due to the echo from these walls. New or Adventitious Sounds are those which are heard only in disease. They are rales or rattling sounds which are produced in the bronchial tubes, in the air vesicles or in cavities, and friction sounds, which are produced by the rubbing against each other of the costal and pulmonary pleura which have been roughened by inflammatory exudate. Rales may be dry or moist. Dry rales are usually caused by narrowing of the tube by spasmodic contraction, or swelling, or a piece of tough mucus sticking to the side. A Foist rates are due to the passage of air through mucus. Dry rales, formed in large tubes, are lozv-pitched or sonorous; those formed in small tubes are high-pitched, or sibilant, or whist- ling. Moist rales, too, vary in size ; those found in large tubes are large, bubbling or mucous ; those in small tubes are much smaller and are called sub-crepitaut. They vary in size. Vesicular rales are those which are formed in the air vesicles; the sound resembles that caused by rubbing the hair between the two fingers. It is called crepitation and is probably due to the pull- ing apart of the sticky walls of the pulmonary alveoli* during inspi- ration. Crackling is the same thing as crepitation, except that the sounds are few in number. Two kinds of rales may be heard over cavities—(i) hollow bub- bling or gurgling, when the cavity has flabby walls, and (2) metallic, when the cavity has tense, elastic walls. Friction sounds are caused by the rubbing against each other o^ two pleural surfaces, roughened by inflammatory exudate. As a rule, the sound usually seems to come from a point very close to the ear. The following table is taken from DaCosta's Medical Diagnosis : Rales of Cavi f Dry or Vibrating { l- h°T pHcl?#d, or sonor°us 'n large tubes. / I 2. High pitched or sibilant in small tubes, I Moist. I I- Large bubbling, or mucous in large tubes. [ \ 2. Small bubbling, or sub crepi;ant, in small tubes. 11. Crepitation, due to tke separation of the walls of the alveoli in inspiration. 2. Crackling—a few crepitant rales. ties l r ,Iollow buW,1ing or gurgling in large cavities with flabby walls. (.2. Metallic in cavities with tense, elastic walls. Bronchial Rales PRACTICE OF MEDICINE. 79 AFFECTIONS OF THE BRONCHIAL TUBES. Acute Bronchitis. Definition.—An acute catarrhal inflammation of the mucous membrane of the larger bronchi. Synonym.—Cold in the chest. Causes.—I. Constitutional predisposition is one of the causes of acute bronchitis; its action cannot be explained 2. Cold and dampness are common causes, probably because they cause a contraction of the blood vessels of the skin and consequent- ly a collateral hyperaemia of the internal organs. 3. Mechanical and chemical irritants, such as the inhalation of ammonia, or of septic matters from the mouth, sometimes occasion the disease. 4. It is a frequent attendant of certain other diseases, such as measles, whooping cough, &c. Morbid Anatomy.— 1. The seat of the disease is in the larger bronchi. 2. The changes in the mucous membrane are swelling and red- ness. 3. The exudate is at first serous or mucous, and is scant; later it becomes more abundant and still later it becomes purulent in character. Symptoms. —1. Respiratory. The only respiratory symptoms as a rule are (1) cough and (2) expectoration. The cough is at first tight and often painful; it is often quite troublesome. The expectoration is at first scant and clear ; a little later much more abundant, clear and frothy, and still later thick and purulent. 2. The nervous symptoms are not marked; a feeling of constric- tion of the chest is present in the early stages and headache is of- ten present. 3. The temperature is rarely elevated to any appreciable extent. Physical Signs.—On auscultation, sonorous and sibilant rales are often heard from the narrowing of the tubes by thick mucus and moist rales are also heard, due to the passage of air through the mu- cus in the tubes. The rales vary in size because tubes of different sizes are involved; sometimes, when only large tubes are involved, there are no 'rales. The Diagnosis is not difficult; it is based on the cough, expec- toration and physical signs. The Prognosis is almost invariably good; there is a possibili- 8o PRACTICE OF MEDICINE. ty that the disease may become chronic or that it may pass into cap- illary bronchitis. Treatment —The indications and mode of fulfilling them are as follows: I. To relieve inflammation by causing hyperaemia of the skin by hot baths, Dover's powders, &c, and by acting on the bowels. 2. To promote expectoration in the early stages by the inhalation of steam, the internal administration of ipecac, &c. 3. To check expectoration, when profuse, by the terebinthinates, such as turpentine, cubebs, &c, and by muriate of ammonia. 4. To relieve cough and soreness by opiates, chloroform and other sedatives. Chronic Bronchitis. Definition.—A chronic inflammation of the bronchial tubes, leading in many cases to increased formation of connective tissue and to cylindrical dilatation of some of the tubes. Causes.— 1. Age. The disease is much more common in eld- erly people than in younger persons, but it may occur at any age. 2. It occasionally follows an acute attack. 3. Mechanical and chemical irritants, if inhaled, may induce the disease. 4. It is often secondary to chronic cardiac, renal or pulmonary disease. These diseases act by interfering with the proper circula- tion of blood through the lungs. Morbid Anatomy. — 1. The mucous membrane is congested and usually thickened, but in very chronic cases it may become smooth and thin. 2. The tubes are often dilated in a fusiform manner from the softening of the tissues and the pressure of the secretions. There is an increase of connective tissue in the peri-bronchial tubes, from the conversion of the white blood cells into connective tissue. Symptoms. — 1. Respiratory. Cough is present in nearly all cases, and is often very harrassing ; it is usually much worse in winter than in summer. The expectoration varies in different cases ; sometimes it is very scant and tough ; sometimes profuse and yellow, and sometimes exceedingly copious and watery. In some cases, especially where the tubes are dilated, the sputa are exceedingly offensive ("fetid bronchitis"). Dyspncea is occasionally present, but is usually due to some complication. 2. Circulatory. The circulatory symptoms in chronic bronchi- tis are not marked, unless there is some obstruction to the flow of PRACTICE OF MEDICINE. 8l Physical Signs.—On inspection there are no marked character- istics in uncomplicated cases. On palpation there is no change in the vocal fremitus, but there may be some rlioncal fremitus. On percussion there is no appreciable change. On auscultation, as a rule, rales of different size and character are heard in consequence of the presence of mucus in the tubes. Diagnosis.—Chronic bronchitis is diagnosed from pulmonary tuberculosis by (i) the absence of dullness on percussion, (2) the ab- sence, as a rule, of any elevation of temperature and (3) the absence from the sputa of the bacilli of tuberculosis. Complications.— 1. Emphysema, to which the bronchitis is usu- ally secondary. 2. Bronchiectasis, which is secondary to the bronchitis and is caused by the accum^ation of secretion in the tubes, which are softened by inflammation. 3. Renal, which usually precede the bronchitis and stand in a causative relation to it. 4. Cardiac. In old cases of chronic bronchitis hypertrophy and dilatation of the right side of the heart occur from the obstruction to the flow of blood through the lungs. Sequelae.— 1. Pulmonary. Bronchiectasis and more or less peri- bronchitis : the manner in which they are produced has already been described. 2. The cardiac have been described under complications. Treatment.— The indications of treatment are: 1. To remove the cause. A change of climate to a mild and warm one in winter is of great importance. To stimulate the action of the kidneys is also important. To improve the general health by tonics and cod liver oil is very important. 3. To check expectoration by the terebinthinate preparations, mu- riate of ammonia, &c. Capillary Bronchitis. Definition.—A catarrhal inflammation of the smaller bronchi. Frequency.—The disease is quite a common one, especially in old persons and young children. Causes.—1. Age. The disease is far more common in old persons and young children than in vigorous adults, because the latter can more readily expel the mucus from the large tubes, and hence inflammation is'less liable to extend to the smaller ones. 11 82 PRACTICE OF MEDICINE. 2. Certain other diseases, such as typhoid fever, measles, &c, which induce debility and permit the inhalation of noxious mat- ters from the mouth or throat. 3. Exposure to cold and dampness, especially when the body is overheated, which causes contraction of the blood vessels in the skin and a sudden congestion of internal organs. Morbid Anatomy.— 1. Seat. In capillary bronchitis the in- flammation is situated in the smaller tubes. 2. Changes in the mucous and sub-mucous coats. The mucous membrane is reddened and swollen; the cells lining it undergo fatty degeneration and peel off; there are also leucocytes in the membrane in considerable number. The sub-mucous tissue is more or less infiltrated with leucocytes. 3. Character of the exudate. The exudate consists of serous fluid or white blood corpuscles, which are mixed with the mucous secretion and with degenerated epithelial cells. Symptoms.— 1. Respiratory. The most striking symptom is dyspnoea, which is due to the swelling of the mucous membrane of the smaller tubes and the consequent obstruction to the entrance of air. Cough is usually troublesome, and is. due to the increased irritability of the terminal filaments of the sensory nerves and to the presence of mucus and exudate in the tubes. Expectoration is usually scanty, because patients with this disease have not sufficient strength to expel the contents of the tubes. 2. Circulatory. The pulse is rapid and very feeble in conse- quence of the exhaustion and the effort of the heart to force the blood on through the vessels. Cyanosis is often present because the swelling of the tubes prevents the entrance of air into the lungs and the blood remains venous. 3. Nervous. The retention of the carbon dioxide in the blood causes restlessness, which in severe cases is followed by gradually increasing stupor and finally coma. Sometimes, especially in chil- dren, the carbon dioxide causes convulsions. 4. Temperature. The temperature is not usually much elevated unless broncho-pneumonia is present as a complication. Some- times in elderly persons it is sub-normal. 5. Cutaneous. Besides the cyanosis, sweating is frequently ob- served, especially about the head. Physical Signs.— 1. Inspection. Both inspiration and expi- ration are rendered difficult by the swelling of the mucous mem- brane of the bronchioles. 2. On palpation there is often no change, though the fremitus may be rendered more feeble than natural by the plugging of a tube. 3. In percussion there is often no change, but sometimes inspi- ration being more powerful than exspiration, the air cells become PRACTICE OF MEDICINE. 83 over-distended, and then there is increased resonance on percus- sion. 4. On auscultation sub-crepitant rales are heard in consequence of the narrowing of the smaller tubes by mucus or the swelling of the mucous membrane. Diagnosis.—It is diagnosed from (i) bronchitis of the larger tubes by the greater dyspnoea, the cyanosis and the sub-crepitant rales; from (2) pneumonia by the absence of bronchial respiration and dullness on percussion. Complications.—1. Collapse of the lung is very common ; it is due to the closure of a bronchus and the absorption of the air in the corresponding part of the lung. 2. Broncho pneumonia is also common; it is due to the exten- sion of the inflammation from the bronchioles into the air vesicles. Prognosis.—The prognosis should be guarded in all cases. The more debilitated the patient the greater the danger. Treatment.—The indications are—1. To reduce inflammation. by causing collateral hyperaemia of the skin by means of poultices, turpentine stupes, &c, applied to the chest, and by the administra- tion of ipecac, if the exhaustion is not too great. 2. To promote expectoration, carbonate of ammonia is the best remedy because it liquefies the sputa and also acts as a stimulant. Ipecac or apomorphia may be used, if the prostration is not too great. 3. To sustain strength by nourishing food and stimulants, such as milk punch, beef tea, wine and carbonate of ammonia. Musk and strychnine are also useful stimulants. 4. To furnish oxygen to the blood by allowing the patient to inhale oxygen gas. Croupous Bronchitis. Definition.—An inflammation of the bronchial tubes in whkh the exudate is fibrinous in character. The disease is very rare. Causes.__The causes are practically unknown. The disease oc- curs most frequently in middle aged men. Morbid Anatomy.—The morbid anatomy is similar to that of simple bronchitis, except that, in addition to the muco-purulent contents of the bronchi, fibrinous casts are also found. Symptoms and Signs.—The symptoms do not differ essential- ly from those of simple bronchitis, except that there are paroxysms of severe dyspnoea from the plugging of a tube or of the tubes 84 PRACTICE OF MEDICINE. with a fibrinous cast. The signs also are similar to those of ordi- nary bronchitis, unless a large tube is plugged, when there is an absence of all respiratory murmur over the lung to which the plugged tube leads. Diagnosis.—The diagnosis is based on the presence of fibrinous casts in the sputa. Prognosis.—The prognosis should be guarded, as about one- fourth of the cases terminate fatally. Treatment.—The inhalation of lime water or of a solution of bicarbonate of soda to give relief by dissolving the fibrinous casts. Iodide of potassium has also been employed. Bronchiectasis. Definition.—A dilatation of the bronchial tubes. Causes.—i. Inflammation, and softening of the tubes, which makes them yield more readily to internal pressure, from secretions or inspired air. 2. Accumulation of secretions, which causes pressure in the tubes, besides softening them. 3. Fibroid phthisis, in which a contraction of the connective tis- sue occurs and thus pulls the walls of the tubes apart so as to cause dilatation. Morbid Anatomy.— 1. Seat. The usual seat is in the lower lobes and there are usually several dilatations. 2. Forms. The dilatations may be cylindrical or sacculated; fre- quently there are ridges projecting into the lumen of the dilatations. 3. Changes in the mucous membrane and zvalls of the bronchi. The mucous membrane frequently undergoes a change; the cili- ated epithelium disappears and its place is taken by a flatter form. There is an increase in the connective tissue surrounding the bronchial tubes, because the white blood cells which pass out dur- ing the inflammation are converted into connective tissue. Symptoms.—1. Respiratory. Cough is a very prominent symptom in most cases; it is especially troublesome, as a rule, soon after getting up in the morning, because the secretions have accu- mulated during sleep and irritate the mucous membrane. The secretion is muco-purulent in character, is usually very abun- dant, and is often fetid because it stagnates in the tubes and o-erms get in and set up decomposition. 2. General. In cases of old standing there is often considerable emaciation, due in part to the excessive discharge of pus and in part to the absorption of septic matters and the consequent fever. PRACTICE of medicine. 85 Physical Signs.— 1. On inspection and palpation there are no changes. 2. On percussion there is increased resonance, provided the dila- tation is of some size, but as a rule it is not marked, and there may even be dullness because of the increased amount of connective tis- sue in the surrounding lung. 3. On auscultation large mucous rales or gurgling are heard un- less the tube has just been emptied by coughing. If the surround- ing lung tissue is more dense than normal, broncho-vesicular or broncho-cavernous breathing are heard. Diagnosis.—It is distinguished from phthisis by (1) the absence, as a rule, of fever and (2) by the absence of the bacilli of tuberculo- sis from the sputa. Prognosis.—The prognosis as to recovery is bad, but persons may live for years in comparative comfort. Treatment.—The treatment is much the same as that of chronic bronchitis. Creosote, eucalyptol and turpentine are of service, and if the discharge is fetid, inhalations of carbolic acid or creosote are indicated. Bronchial Asthma. Definition.—A disease characterized clinically by difficulty of breathing, especially on expiration, and by the presence of rales varying in size and character, and heard with great distinctness over both lungs. The disease occurs in paroxysms. Pathology.—Two views are held as to the nature of the dis- ease— 1. The probable cause of the difficulty of breathing is a spasm of the muscular coat of the bronchial tubes. 2. Sir Andrew Clarke and others think the difficulty of treating is due to an eruption, like that of nettle rash, on the mucous mem- brane of the tubes, and the consequent obstruction to the ingress and egress of air. Causes.—Heredity is a predisposing cause; no", simply the oc- currence of asthma in some ancestor, but the existence of any functional nervous disease. The existing causes are — 1. Certain irritants, differing in different people. 2. Diseased condition of the nose, stomach, bowels, &c, which cause asthma by reflex action. 3. Certain diseases of the lungs or heai't, such as emphysema, bronchial catarrh, mitral obstruction, &c. 4. Retention of urinary matter in the blood, which probably acts by irritating the respiratory centre in the fourth ventricle. 5. Tumors of the fourth ventricle. 6. Irritation of the vagus in its course. 86 PRACTICE OF MEDICINE. Symptoms.—Sometimes premonitory symptoms occur, such as the passage of large quantities of limpid urine, but they arc often absent. i. The onset is usually rather sudden. 2. The position and appearance is quite characteristic. The pa- tient isunable to lie down, and in severe cases leans forward. The face is more or less livid from interference with respiration, and the skin is bathed in sweat. 3. Respiratory. Dyspnoea is the most prominent symptom and this is especially great on expiration. Cough is usually very trou- blesome, but the secretion is tough and scant. Speech is embar- rassed from the difficulty of respiration. 4. Circulatory. The pulse is small and weak, and the veins are distended in consequence of the interference with the exchange of gases in the lungs. Physical Signs.—1. On inspection the chest is observed to be distended, and the respiratory movement slow and labored. 2. On palpation the rhoncal fremitus is very marked. 3. On percussion there is tympanitic resonance, in consequence of the over-distension of the air cells, because the inspiratory mus- cles are much stronger than the expiratory. 4. On auscultation, dry rales of all sizes and characters are heard in consequence of the narrowing of the tubes. Diagnosis.—It is distinguished from—1. Spasmodic affections of the larnyx by (1) the absence of rales, and (2) the greater difficulty in inspiration in the latter. 2. Capillary bronchitis by (1) the existence of fever, (2) the finer character of the rales, and (3) the greater difficulty in inspiration in the latter. 3. Pulmonary oedema and congestion, by the mucous rales and liquid sputa in these affections. 4. Cardiac dyspnaa by the evidences of heart disease. Prognosis.—The prognosis in simple asthma is always good as to life, but bad as to permanent recovery. Complications.— Emphysema of the lungs and bronchitis are common complications. Treatment.—1. To remove the cause, by relieving diseased conditions of the nose, stomach or bowels. 2. To relax spasm, by (1) depressing remedies, such as ipecac, lobelia and tobacco, or (2) by sedatives and antispasmodic, such as amyl nitrite, opium, chloroform, chloral, quebracho, nitre, grindelia. robusta, &c, or (3) by stimulants, such as alcohol and coffee. 3. To build up the nervous system by quinine, &c, and to lessen the tendency to spasm of the involuntary muscular fibre by nitro- glycerine and other drugs of its class. PRACTICE OF MEDICINE. 87 4. Certain drugs, such as iodide of potassium, have been found very useful in preventing the paroxysms, though their mode of ac- tion is not known. Probably the iodides act by allaying the inflammation and swelling of the bronchial glands. 5. Inhalations of the fumes from nitre paper are very useful in relieving the paroxysms. Pyridin has also been of service. Pulmonary Emphysema. Definition.—A disease characterized by dilatation of the air vesicles with thinning and subsequent rupture ot the partitions be- tween them and destruction of many of the pulmonary capillaries. Varieties-—The definition applies to vesicular emphysema ; in- terlobular emphysema is the escape of air into the connective tissue between the pulmonary lobules. Causes. — 1. Forced expiration with the glottis closed, as occurs in violent straining, or among persons who use wind instruments. 2. Impaired elasticity and nutrition of the lungs; hence it occurs most commonly in elderly persons and is often hereditary. 3. Solidification or collapse of one part of a lung, or of one lung. may occasion emphysema of some other part, (compensatory em- physema ) Morbid Anatomy.—1. Size. The lungs are greatly distended and overlap the heart to a greater or less extent. The chest is en- larged and barrel-shaped. 2. Changes in tJie air vtsides. The air vesicles are distendt d and the partitions atrophied and ruptured so that large air spaces or sacs are formed, especially in the apices of the lungs where they are not protected by rigid chest walls. The capillary blood vessels on the walls of the alveoli undergo atrophy. 3. Changes in neighboring viscera. The permanent distension of the lungs with air forces the heart downwards and also causes de- pression of the liver and other abdominal viscera. In old cases there is hypertrophy and dilatation of the right side of the heart from obstruction to the flow of blood through the lungs. Complications and Results.— 1. Bronchitis is present as a com- plication in nearly every case of emphysema and adds to the gravity of the affection. 2. Hypertrophy and dilatation of the right side of the heart results from the destruction of the pulmonary capillaries and the consequent obstruction to the flow of blood through the lungs. Symptoms.—1. Respiratory. Dyspnoea, increased by exertion, is the most prominent respiratory symptom. It is due to (1) the loss 88 PRACTICE OF MEDICINE. of elasticity of the lung tissue and the consequent inability to empty the lungs, (2) to the destruction of the pulmonary capillaries, (3) to the loss of tone of the diaphragm and (4) to the accompanying bron- chitis. Cough and expectoration of tough mucus are commonly present and are due to the accompanying bronchitis. 2. Circulatory. The pulse is small and weak (unless arterio- sclerosis is present as a complication), because but little blood passes through the lungs to the lett side of the heart. The venous system is engorged in consequence of the dilatation of the right side of the heart, and the liver and spleen, are usually enlarged. 3. Urinary. The urine is scant and high-colored, from the lowering of the tension in the arteries. 4. General. In cases of long standing there is serious impair- ment of the flesh and strength in consequence of the defective cir- culation and nutrition. Physical Signs.—1. On inspection the chest is observed to be barrel-shaped, trom the inability to expel the air from the lungs, and the consequent distension ; and in breathing the chest moves as a whole. In severe cases pulsation of the jugulars occurs from tricuspid insufficiency. 2. The sound on percussion is vesisculo-tympanitic, in conse- quence of the increased quantity of air in the chest. 3. On auscultation the respiratory murmur is found to be fainter than natural, because the amount of air retained in the lungs from the loss of elasticity interferes with the entrance of air. Diagnosis.—It is distinguished from pneumothorax by the involvjmjut of both lungs and its gradual onset. Prognosis.—The disease is dangerous only from the compli- cations and results, which are always serious. Treatment. — 1. To improve nutrition by tonics, especially cod- liver oil. 2. To prevent or lessen complications by residence in a dry cli- mate and by the proper treatment of bronchitis, &c. 3. To lessen expansion of the clvcoliby exhaling into a rarified at- mosphere and by inhaling compressed air. Compression of the chest by mechanical means, during expiration, for a short time every day is of great service. 4. To relieve dyspnoea by quebracho and grindelia robusta. PRACTICE OF MEDICINE. 89 Acute Lobar Pneumonia. Synonyms.—Croupous pneumonia, pneumonic fe^er, lung fever. Definition.—An acute, infectious disease, characterized by its sudden onset, high temperature and by inflammation of one or more lobes of the lungs. Causes.—1. A germ is propably the essential cause of pneu- monia ; bnt it is doubttul whether the oval coccus described by Friedlander is always the infecting agent. 2. Age. The disease may occur at any age, but is most common in young adults. 3. Sex. It is rather more common in men than in women, be- cause they are more exposed to the existing causes, such as change of temperature. 4. Depression of vital powers from any cause, such as alcoholism, malaria or any severe illness, which renders the system less re- sistant than natural. Organic heart diseases probably act in the same way. 5. One attack renders a person more liable, apparently, to subse- quent ones, partly, perhaps, by impairing the general health and partly because of some natural want of resistance to the germs in some people. 6. A changeable climate and the winter and spring seasons un- doubtedly exert a causative influence, chiefly, perhaps, by causing contraction of the cutaneous blood vessels and consequent collateral hyperaemia of internal organs. Morbid Anatomy.—The lower lobe of the right lung is most commonly involved. The disease presents three stages.—First stage, or stage of en- gorgement— 1. The color is darker than natural, because the amount of blood in the lungs is increased. 2. In consistence the lung is softer than natural and pits on pres- sure because of the increased amount of fluid in it (liquid exudate). 3. On section the air cells are found to contain a more or less bloody and viscid fluid; the capillaries are distended with blood and the epithelium lining the alveoli has undergone fatty degenera- tion and in some places is desquamating. Second stage or stage of red hepatization.— 1. The color is very dark. 2. The consistence is very firm because the alveoli are filled with a fibrinous exudate. 3. 'On section or fracture the alveoli are found to be filled with fibrinous plugs, giving the lungs a granular appearance. There is little or no liquid discharge on section in this stage. Third stage or stage of gray hepatization.— 1. The color is giay and mottled — redder in some parts than in others. 2. The consistence is softer than in the second stage. 12 QO PRACTICE OF MEDICINE. .3. On section, the alveoli are found to be filled with white blood (or pus) cells, red blood corpuscles and granular matter, the white cells being in excess. It is doubtful whether this stage ever occurs except in fatal cases. It is sometimes called the stage of purulent infiltration. The duration of the first stage is from six to twenty-four hours; that of the second stage from five to nine days. Symptoms.— 1. The onset is nearly always sudden. 2. The nervous symptoms are, (1) a chill at the commencement, which is usually violent in character, (2) pain in the chest, which is due to the accompanying pleurisy, (3) headache and subsequently delirium, due to the circulation of venous blood probably contain- ing leucomaines. 3. The temperature rises rapidly to 1040, 105 °, or possibly even higher, and continues at this point for from five to nine days, when it usually falls suddenly to the normal. 4. The respiratory symptoms are, (1) rapid and panting breath- ing, due to the lessening of respiratory space. (2.) Cough; usually very troublesome, which is due to the irrita- tion of the terminal filaments of the sensory nerves in the lungs, (3) expectoration at first of a tough mucus which soon becomes stained with blood {rusty sputa) and is exceedingly tenacious, and later be- comes more liquid and copious from the liquidation and breaking down ot the exudate. 5 Circulatory. The pulse is rapid and full in the early stages because of the high temperature, but later on it often becomes weak from the albuminoid degeneration of the heart muscle.' 6. Cutaneous. The skin is very hot and dry in the early stages, but when the crisis comes there is often a profuse sweat and some- times even before the crisis sweating occurs. The face has a dusky look and there is a flush in one cheek. 7. Digestive. Anorexia is the rule, and nausea and vomiting may occur; the bowels are usually constipated, but in very severe cases troublesome diarrhoea sometimes occurs. 8. Urinary. The urine is scant and high colored and the chlo- rides are greatly diminished in quantity. Albumin is frequently present in small amount, and there may be a considerable quantity, especially when the apex of the lung is involved. The albuminuria is probably caused by the elimination of leucomaines by the kfd- neys. Physical Signs.—In the first stage or stage of congestion.—1. On inspection the respirations are seen to be hurried and the move- ments on the affected side are less free than normal, (1) because the air cannot enter the lung as well as in health, and (2) because of the pain occasioned by the position of the inflamed pleural surfaces against each other. PRACTICE OF MEDICINE. 91 2. On palpation the vocal fremitus is slightly increased because of the commencing consolidation of the lung. 3. On percussion there is some dullness for the same reason. 4. On auscultation crepitant rales are heard over the inflamed lung: these rales are heard especially during inspiration, and are probably due to the pulling apart of the agglutinated walls of the air vesicles. Pleuritic friction sound is usually heard also because pleurisy is such a common complication of pneumonia. In the second stage or stage of consolidation.—1. Inspection shows an absence of respiratory movement over the affected lung because it is impervious to air. 2. On palpation the vocal fremitus is greatly increased because vibrations are carried better through a solid than a gaseous me- dium. 3. On percussion there is very marked dullness because there is very little air in the lung. 4. On auscultation there is bronchial breathing because the solidi- fied lung tissue conveys the sound from the bronchial tubes to the ear far better than the healthy lung, which contains air. The ve- sicular murmur is lost because the air vesicles are filled with a firm substance and no air can enter them. In the third stage, if the lung tissue is clearing up, the signs are very much like those of the first stage. If purulent infiltration occurs, liquid rales are heard over all parts of the diseased lung. Diagnosis.—1. From pulmonary congestion and oedema, pneu- monia is distinguished by the chill, sudden onset and high tempera- ture in the latter. 2. From acute capillary bronchitis by the different onset and by the fact that bronchitis involves both sides and does not cause solidification of the lung with the consequent physical signs. 3. From acute pleurisy by the absence of dullness on percus- sion and bronchial breathing in pleurisy. 4. From hypostatic congestion by the sudden onset and high temperature of pneumonia, which is not seen in hypostatic conges- tion. 5. From lobular pneumonia by the fact that this disease is al- ways secondary; that the lobules of the lungs are involved and that the fever is less high. Complications.—1. Pleurisy is a very common complication from extension of the inflammation to the pleura overlying the diseased lung. 2. Pericarditis sometimes occurs, probably from extension. 3. Meningitis is a rare complication, and may occur in any acute infectious disease. 4. Congestion of the liver and spleen generally occurs, as in other infectious diseases. 92 PRACTICE OF MEDICINE. 5. Gastro-intestinal catarrh is sometimes a serious complica- tion, but is not a very common one. Nature of Pneumonia.—Pneumonia is probably an acute infectious disease, because it resembles them in the following par- ticulars— 1. Character of invasion. 2. Cyclical course—from four to nine days. 3. It is not caused by injuries. 4. It is sometimes epidemic and apparently contagious. 5. The complications are like those of the acute infectious diseases. 6. The general symptoms are often out of proportion to the lo- cal disease. Terminations.—1. Resolution and absorption of the inflamma- tory exudate is much the most common termination. 2. Purulent infiltration is especially apt to occur in elderly and debilitated persons, and nearly always terminates fatally. 3. Abscess and gangrene are rare terminations. 4. Chronic pneumonia is also a rare termination. Prognosis.—The prognosis in uncomplicated cases and in pre- viously healthy persons is usually good ; but is materially influ- enced by the following circumstances:—I. Age. The danger is very much greater in old persons than in vigorous adults for ob- vious reasons. 2. Extent and situation of the disease; pneumonia of the apex is more serious than pneumonia of the base, and of course the greater the surface involved the greater is the danger. 3. The general condition of the patient is of great importance in prognosis; debility from any cause greatly increases the danger. The circumstances, however, which most seriously influence the prognosis are intemperance and malaria. 4. A very high temperature, if prolonged, renders the prognosis unfavorable. ^5. Complications of any kind increase the danger; especially is this true of pericarditis and malarial poisoning. Causes of Death.— 1. Asphyxia is sometimes a cause of death in double pneumonia. 2. Asthenia, from the prolonged high temperature and the de- generation of the heart muscle, is the most common cause. 3. Thrombosis in the cavities of the heart or of the pulmonary artery is an occasional cause of death. 4. Urincemic poisoning occasionally occurs when kidney com- plications are present. Treatment.—The indications and means of fulfilling them are briefly as follows—1. To relieve pain by morphia, cups and poul- . tices. PRACTICE OF MEDICINE. 93 2. To lessen the amount of blood in the lungs, by (1) remedies which dilatate the vessels in the skin, such as poultices externally, and aconite, veratrum, ipecac, &c, internally; (2) lessening the force and frequency of the heart's action by aconite, veratrum, &c. 3. To reduce the temperature by cold baths (which must be used with great caution), phenacetine, antipyrine, quinine, &c. 4. To facilitate respiration, especially in double pneumonia, by inhalations of oxygen, and possibly by bleeding in robust patients. 5. To sustain strength, by food and stimulants, and by digitalis when heart failure is threatening. Carbonate of ammonia is es- pecially useful. 6. To avoid complications by proper attention to diet and other hygienic measures. Lobular Pneumonia. Synonyms. — Broncho-pneumonia, catarrhal pneumonia, sec- ondary pneumonia. Definition.—An inflammatory affection commencing in one or more lobules of the lung and frequently spreading to adjacent lob- ules. Causes.— I. It is secondary to bronchitis or collapse of the lung 2. It is more common in children than in adults, because the small size of their tubes renders them more liable to collapse. 3. Bad hygienic surroundings by causing debility increases the liability to it. 4. Injuries to the lungs, or the inhalation of noxious matters, • as in typhoid fever, act as causes by direct irritation. 5. It is frequently secondary to, or a complication of, measles, whooping cough, diphtheria, etc. Morbid Anatomy. —i. Seat. Usually in the lower back part of the lungs, because inhaled or inspired sub.stances are most apt to lodge there. 2. Extent. The disease commences usually in one lobule or in several which are scattered through the lungs, but several such lobules may unite to form a large patch. 3. Color. The color is dark from the presence of blood in the vessels in greater quantity than normal. 4. The consistence is firmer than that of the healthy lung, but it is less resistant to a tearing force because of the saturation with the exudate. . 5. The bronchi are inflamed and contain a muco-purulent fluid. 6. The alveoli contain the exudate characteristic of catarrhal inflammation, namely, pus cells, large cells much like epithelium, 94 PRACTICE OF MEDICINE. a certain amount of granular detritus and mucus. The cells lin- ing the alveoli undergo granular and fatty degeneration, and peel off. The capillaries are distended with blood. Symptoms.— i. Those of the preceding disease. 2. Respiratory. The cough is usually troublesome, because of the accompanying bronchitis. The expectoration is thinner, more muco-purulent in character than in lobar pneumonia because of the catarrhal inflammation; it is usually blood-stained, but in chil- dren the sputa may be swallowed, so that the amount and character cannot be determined. The degree of dyspnoea depends upon the amount of lung tissue involved and upon the degree of obstruc tion of the bronchial tubes. As a rule it is much less than in lobar pneumonia, because less lung tissue is implicated and the tempera- ture is not so high. 3. Circulatory. The pulse is usually rapid and feeble, chiefly in consequence of the debilitating effect of the preceding disease. 4. Digestive. Anorexia is the rule, and nausea and vomiting occasionally occur. The bowels are usually constipated from the loss of tone of the muscular coat, but intestinal catarrh may occur. 5. Nervous. A chill of moderate intensity usually occurs at the commencement of the attack. A stitch in the side is also a fre- quent symptom, but it is less frequent and less severe than in lobar pneumonia. 6. General. Debility and pallor are usually very marked in cases of lobular pneumonia, but they are attributable rather to the preceding disease than to the pneumonia itself. Physical Signs. — 1. On inspection there is usually but little change from health in the fulness of the respiration, because the amount of lung tissue involved is not sufficient to interfere with the inflation of the lungs. 2. On palpation, if the hand be placed over the solidified lung tissue, the vocal fremitus will be found to be increased. 3. On percussion, there is dullness over the inflamed spot be- cruae of the diminution in the quantity of air in that part of the lung. 4. On auscultation, there is bronchial breathing for the same reason, and there are, as a rule, rales varying in size, but chiefly sub-crepitant, which are due in great part to the presence of mucus in the tubes. Diagnosis.—It is diagnosed from—1. Lobar pneumonia, by the fact that it is secondary, that its onset is more gradual, that a much smaller surface is involved, and that the temperature i6 not so high and the disease does not run a definite course, as lobar pneumonia does. 2. Capillary broncliitis, by the rusty sputa and bronchial breath- ing, which are absent in bronchitis. PRACTICE OF MEDICINE. 95 3. Acute tuberculosis, by the lower temperature, the slighter degree of prostration, and the absence from the sputa of the bacilli of tuberculosis. 4. Collapse of the lung, by the sudden occurrence of the latter and by the absence of bloody sputa and ft ver. Complications.— I. Capillary bronchitis is a very common complication, and is very often a cause of the pneumonia. 2. Fibroid induration of the lung in cases of long duration. 3. Tuberculosis is a not uncommon complication, because the lobular pneumonia furnishes a suitable soil for the development of the bacilli of tuberculosis. 4. Pleurisy from extension of the disease to the over lying pleura. 5. Acute intestinal catarrh, which is especially common in chil- dren, and is due, in part, at least, to the swallowing of substances which should be expectorated. Prognosis.—The prognosis is usually more serious ihan that of lobar pneumonia, because of the debility from the preceding disease. The duration is always, as a rule, longer than that of lobar pneu- monia. The circumstances influencing the prognosis are, (1) the preced- ing disease, (2) the age and health of the patient, (3) the height of the fever. Terminations.—The terminations are — 1. Resolution, which is the most frequent termination in healthy persons. 2. Chronic pneumonia, which is especially apt to occur in de- bilitated persons surrounded by bad hygienic conditions. 3. Pulmonary phthisis, from the caseation and softening of the inflammatory exudate. 4. Bronchiectasis, from the softening of the tubes and from the fibroid induration of the lung tissue, which occurs in cases of old standing. Causes of Death.— 1. Asphyxia, when a number of lobules are involved, or when capillary bronchitis co-exists. 2. Asthenia, or exhaustion, which is much the most common cause of death. 3. Complications, especially capillary bronchitis. Treatment. — 1. To cure the preceding disease. 2. To draw blood to the skin by hot applications, such as poul- tices, turpentine stupes, &c. 3. To lessen fever by phenacetine, quinine, &c. 4. To sustain strength by stimulants and food and by carbonate of ammonia and digitalis, if the heart's action is weak. 5. To avoid hypostasis by frequent changes of position and by the use of cardiac stimulants. 96 PRACTICE OF MEDICINE. 6. To prevent evil results, such as chronic pneumonia, by stimu- lants, tonics, fresh air and nourishing food. Hyper.emia of the Lings. Definition.—An excessive quantity of blood in the lungs witli out actual inflammation. Varieties.—I. Active, due to the excessive influx of arterial blood. 2. Passive, due to the obstruction to the outflow of venous blood. Causes.—The causes of active hyperaemia of the lungs, are:— i. Alcohol, which increases the force and frequency of the heart's action and dilates the blood vessels. 2. Exertion, which acts in a similar manner. The cause of fiassive hyperaemia of the lungs is usually obstruc- tion at the mitral orifice, but regurgitation, or leaking at the same orifice, will have a similar effect. Morbid Anatomy.— I. The color of the lungs is darker than normal from the excessive amount of blood in them. 2. The consistence of the lungs is increased because the relative amount ot air is lessened. 3. The capillary vessels are distended with blood. 4. The alls ot the alveoli show albuminoid degeneration. 5. In cases of long standing, brozon induration occurs from the deposit of blood pigment in the tissues ; this occurs especially in passive hyperaemia. Symptoms.— 1. Respiratory. Cough is usually quite trouble- some. The expectoration in severe cases of active hyperaemia is blood stained ; in the passive form it is usually quite copious and liquid. Dyspnoea is present in greater or less degree from a simple sensation of tightness across the chest to decided difficulty of breath- ing. It is due to the over-filling cf the lungs with blood and the consequent failure in the proper exchange of gases. 2. Circulatory. In the active form the pulse is full and strong; in the passive, usually weak and feeble, the pulmonary second sound accentuated from the increased pressure in the pulmonary artery, and there is engorgement of the systemic veins in cases of long standing. 3. The temperature is not elevated. Physical Signs.— 1. On percussion there is usually slight dull- ness because the air space is lessened. 2. On auscultation there is sometimes broncho-vesicular breath- V practice of medicine. 97 ing and rales are heard. In the passive form they are usually abundant and moist. Diagnosis.—The diagnosis is based on:—I. The dyspnoce. 2. The bloody sputa. 3. The absence of fever. 4. The existence of causative conditions. Prognosis.—In the active form the prognosis is usually good, because the causes can be removed. In the passive form it is usually bad, because the causes are in- capable of removal. Treatment.—To lessen the amount of blood in the lungs.—1. In the active form by (1) remedies which lessen the amount of blood, such as bleeding or wet cups, (2) dilating the vessels of the skin by poultices, &c, (3) lessening the force and frequency of the heart's action by aconite, &c. 2. In the passive form by agents which increase tlie force of the heart, such as stimulants and digitalis. To relieve the pulmonary oedema, which often occurs from pas- sive hyperaemia, hydragogue cathartics are indicated. CEdema of the Lungs. Definition.—The accumulation of fluid in the air vesicles and interstitial tissue of the lungs. Causes.—Pulmonary oedema is always secondary to— 1. Bright's disease. 2. Passive hyperemia, which causes overfilling of the veins and consequent transudation of serum from malnutrition of the walls of the vessels. 3. Certain exhausting diseases which act by inducing malnutri- tion of the walls of the vessels, and also weakness of the heart. 4. Old age and position (hypostasis) probably act in the same way. Morbid Anatomy.—The morbid anatomy consists solely in the presence of an excessive amount of watery fluid in the air cells and interstitial tissue of the lungs. Symptoms. — 1. Respiratory. Dyspnoea is usually excessively severe from the loss of aerating space. Cough is troublesome until the patient becomes benumbed by the carbonic acid which is re- tained in the blood. The expectoration is liquid in character, but may be viscid. 13 98 PRACTICE OF MEDICINE. 2. Circulatory. The pulse is usually very feeble and the skin cyanotic. Physical Signs.— 1. On percussion there is more or less dull- ness in consequence of the presence of fluid in the air cells. 2. On auscultation great numbers of liquid rales, varying in size, are heard over both lungs. Diagnosis.—It is distinguished from—1. Pneumonia by the absence of fever, the absence of bronchial respiration, as a rule, and by the liquid character of the sputa. 2. Hydrothorax by the liquid rales heard on auscultation, and by the absence of flatness on percussion. 3. Capillary bronchitis by the different causative diseases*in the two cases and by the fever which is present in bronchitis. Prognosis.—The prognosis is usually bad because of the gravity of the causative disease. Treatment.—The indications of treatment and the means of fulfilling them are—I. To increase the pozver of tJie heart by stimu- lants and digitalis. 2. To drazv blood to the surface by dry cups ; poultices are not proper here, because they may cause debility. 3. To remove the zvater by diaphoretics, diuretics and hydra- gogues. 4. To lessen dyspnoea by the inhalation of oxygen. Infarction of the Lungs. Definition.—The extravasation of blood into the substance of the lungs and air vesicles from the plugging of a branch of the pulmonary artery. (See Infarction in general pathology.) Causes.— 1. Disease of the Fieart, especially of the mitral valve, leading to stagnation in the right side of the heart and consequent coagulation of the blood there —a piece of such coagulum being subsequently swept into the pulmonary artery. 2. The lodging in the pulmonary artery or its branches of an embolus from the systemic veins. Morbid Anatomy. —1. The seat of an infarction is usually near the surface of the lung. 2. It is triangular in shape from the arrangement of the vessels ; it varies in size; it is firm in consistence, but tears readily. 3. The color is dark from the great increase in the amount of blood in that part of the lung. 4. The pleura over the infarction is inflamed. 5, The blood vessels and alveoli are filled with venous blood. practice of medicine. 99 Symptoms.—The symptoms and signs depend in great meas- ure on the size of the infarction. i. The respiratory are cough, dyspnoea, tightness across the chest and the expectoration of dark blood. The cause of these symptoms is the engorgement of the part of the lung involved and the consequent diminution of breathing space. 2. The circulatory symptoms are engorgement of the venous system and usually weak and rapid pulse. 3. The most prominent symptom connected with the nervous system is pain, which is due to the accompanying pleurisy. 4. The temperature is slightly elevated, but rarely rises above 102°. Physical Signs.—1. On percussion there is dullness, the extent of which depends, of course, upon the size of the infarction. 2. On auscultation there are often coarse mucous rales, and bron- chial breathing is also present after a short time. Diagnosis.—The diagnosis is based on (1) the presence of dis- eases which would lead to infarction and (2) the character of the sputa. Termination.— 1. Resolution, if the infarction is not large and the generaThealth is good. 2. A cyst may form from inflammation around the infarction and the partial absorption of the infarction itself, so that the contents of the cyst are cheesy or chalky matter. 3. Pneumonia may also occur as a termination and is usually of a very severe grade. 4. Gangrene or abscess]may occur when the embolus leading to the infarction is infective. Prognosis.—The prognosis depends upon the cause and uatuit of the embolus, but is always serious except in the mildest cases. Treatment.—The treatment consists in sustaining strength by rest, nutritious food and stimulants and the stimulation of the heait by digitalis. Gangrene of the Lung. Varieties. — 1. Diffuse. 2. Circumscribed. Causes.—1. The entrance into the lungs of organic matters, such as particles of food, pieces of tissue from cancerous growth, &c. This is especially apt to occur in insane patients and drunk ards, or in persons who have paralysis of the muscles of degluti tion. IOO practice of medicine. 2. Certain pulmonary affections, especially interstitial pneumonia may cause it. Morbid Anatomy.—i. In the diffused form, the whole lung may be softened and gangrenous without any line of demarkation. 2. In the circumscribed form the gangrenous patch is usualliy situated in the lower back part of the lung, and is surrounded by a form of catarrhal pneumonia. Symptoms. — i. Respiratory. Fetid breath, more or less dys- pnoea and cough, and the expectoration of shreds of lung tissue, constitute the respiratory symptoms and need no explanation. 2.. The general symptoms are those of exhaustion. 3. The temperature is usually elevated, 1030 to 1050, but if there is a free vent for the gangrenous matter there may be no fever. Complications.—Empyema, intestinal disturbances and abscess of the brain may occur as complications. Diagnosis.—The diagnosis is based on (1) the fetor, and (2) the presence in the sputa of shreds of lung tissue. Probably the with- drawal of fetid gases from the pleural cavity by aspiration would be useful. Prognosis.—The prognosis is bad, but in circumscribed cases recovery may occur. Treatment.—The indications are—1. To sustain strength by tonics, nutriment and stimulants. 2. To lesson the fetor of the discharge by inhalations of tur- pentine and the use of turpentine internally. Carbolic acid and creosote may be used in the same way. 3. Thoracotomy and the removal of the gangrenous tissue is sometimes useful. Collapse of the Lung. Definition and Synonym.—In collapse of the lung or atelectasis, the pulmonary tissue in a part of the lung is devoid of air. Causes.—1. Age. It is much more common in childhood than in after life, because the exciting causes, such as whooping cough, &c, are more common then. 2. Debility. Weakly children are more liable to it than strong ones, because the respiratory muscles do not act with sufficient force to draw air into the lungs. 3. Bronchitis is one of the commonest of the existing causes. A tube becomes plugged with mucus and the air in the correspond- ing part of the lung is gradually absorded. practice of medicine. IOI 4. Whooping cough is also a common cause; the air is forced out of a part of the lung during violent expiration and the lung is not re-inflated. 5. Intra-thoracic pressure, as from pleural effusion, is also a cause. Morbid Anatomy.—1. Seat. The usual seat of atelectasis is on the surface of the lower back part of the lungs. 2. Color and consistence. The color is bluish and the consist- ence firmer and tougher than natural. The lung is airless and does not crepitate. It sinks in water. 3. The bronchi usually contain mucus and are occluded by it. Symptoms.—\. Respiratory. The respirations are feeble and shallow. Cough is usually present because of the accompanying bronchitis. 2. Circulatory. The pulse is rapid and feeble, and there is blue- ness of the surface because of the obstruction to the flow of blood through the lungs. Physical Signs.— 1. On inspection it will be seen that the move- ments of the chest are not as free as they should be, and in bad cases there is sinking-in of the supra-clavicular region and the ab domen on inspiration, in consequence of the failure of inflation of the lung. 2. On percussion there is dullness over the collapsed spots; and 3. On auscultation bronchial breathing is heard over them. Diagnosis.—It is diagnosed from—1. Pneumonia, by the ab- sence ot fever and bloody sputa. 2. Tuberculosis, by the absence of fever and the seat of the disease—at the lower part of the lung. Pleurisy, with effusion, by the absence of flatness on percussion, and the change ot level of the fluid in pleurisy, when the position is changed. Results.—A very common result of collapse of the lung is broncho-pneumonia. Prognosis.—The prognosis depends, in great measure, on the previous state of health, but it is usually bad, especially after whooping cough. Treatment. — 1. To stimulate respiration, by cold douches, strychnine and other respiratory stimulants. 2. To relieve the causatiz'c conditions, such as bronchitis. 3. To improve the general health, by nutritious food, cod liver oil and stimulants. 102 PRACTICE OF MEDICINE. Acute Pleurisy. Definition.—An acute inflammation of the pleura. Causes. — I. Exposure to cold and dampness is probably a cause of acute pleurisy. 2. Injuries, such as fracture of the ribs or wounds of the chest, will cause it. It is often an accompaniment of other diseases, such as pneu- monia, Bright's disease and the acute infectious diseases. Morbid Anatomy.—i. The color of the membrane is changed so that it becomes reddened and cloudy. 2. In texture it. is softened and the cells undergo granular de- generation. 3. The exudate is fibrinous in character, but there is probably in all cases more or less liquid exudate also. The pleural surfaces are roughened by the exudate. Results.—As a result of the inflammation the pleura becomes thickened and adhesions are formed between the costal and pulmo- nary pleura. Symptoms.— 1. Nervous. Pain is one of the most striking of the symptoms of acute pleurisy ; it is due to the rubbing against each other of the inflamed surfaces, and is increased by breathing. 2. Respiratory. The respiration is hurried and shallow because of the pain which it occasions. There is more or less cough, but no expectoration in simple cases. 3. Circulatory. The pulse is small and rapid. 4. The temperature is elevated but rarely goes above 1020. Physical Signs.—1. On inspection, the respiratory movements are seen to be shallow and hurried. 2. On palpation, friction fremitus can often be detected, caused by the rubbing against each other of the surfaces roughened by the exudate. 3. On percussion, there is no change unless the amount of effu- sion is large, when there will be flatness over the seat of effusion. 4. On auscultation, a friction sound is heard in consequence of the rubbing against each other of the inflamed surfaces. If there is much liquid exudate the surfaces are held apart and the friction sound is absent. Diagnosis.—It is diagnosed from—1. Pneumonia, by the ab- sence ot dullness on percussion and of rusty sputa, and also by the temperature, which is much higher, as a rule, in pneumonia. 2. Intercostal neuralgia, by the absence of fever, as a rule, in neuralgia and the absence of the physical signs of pleurisy. Prognosis.—The prognosis of acute pleurisy is usually good, but adhesions always result. PRACTICE OF MEDICINE. IO3 Treatment.— 1. To relieve pain by opium and rest, and by counter-irritants, such as turpentine stupes. 2. To build up the general health after the acute stage of the attack has passed, by tonics, such as iron and cod-liver oil. 3. To promote the free expansion of the lungs after the acute stage has passed, by means of gymnastic exercises. Sub-Acute or Serous Pleurisy. Definition.—Frequency. A sub-acute inflammation of the pleu- ra with serous exudate usually in considerable amount. It is quite frequent. Causes.—1. The disease is usually secondary to Bright's dis- ease or phthisic. 2. Exhaustion or exposure to cold and dampness may cause it, however; they usually act as exciting causes. Morbid Anatomy.— 1. One side only is usually involved. 2. Color and consistence. The pleura loses its lustre and be- comes softened. 3. The exudate is liquid and may nearly fill one side of the chest. 4. The lung on the affected side is collapsed and pressed up- ward and backwards. The heart is pushed toward the sound side by the effusion. 5. At a late stage after the fluid is removed there are adhesions and the chest may be retracted if the lung does not expand again. Symptoms.—1. Respiratory. The dyspnoea is usually consid- erable from diminution of respiratory space which is caused by the pressure of the effusion. It is greatly increased by exertion. 2. Circulatory. The pulse is rapid and feeble, especially on ex- ertion. 3. The temperature is rarely elevated unless the pleurisy is as- sociated with phthisis. 4. The general symptoms are pallor and exhaustion. Physical Signs.—1. On inspection the chest is enlarged on the diseased side, and if the effusion is great there is bulging of the in- tercostal spaces. Respiratory movement is absent. 2. On palpation there is loss of vocal fremitus. 3. On percussion there is flatness over the effusion. 4. On auscultation there is absence of all respiratory sound over the effusion and bronchial respiration over the upper back part *of the chest where the compressed lung is situated. Diagnosis.— 1. From pneumonia and plitliisical consolidation, pleurisy is distinguished by the absence of bronchial breathing over the effusion and the absence of fever, as a rule. IO4 PRACTICE OF MEDICINE. 2. From a tumor in the chest it is diagnosed by the result of as- piration. Prognosis.—The prognosis is usually favorable, but phthisis is a probable sequel. Treatment — i. The first indication is to improve the general healthby means of the syrup of iodide of iron, nutritious food, stim- ulants and fresh air. 2. To remove the effusion when the respiration is seriously em- barrassed by means of concentrated saline solutions and aspiration. Empyema. Definition and Varieties.—A collection of pus in the pleural cavity; it may be primary or secondary to some injury, or to phthisical perforation of the pleural cavity. Causes.—I. An injury which admits germs to the pleural cavity. 2. Phthisis which perforates the pleural cavity and allows germs to enter. 3. Debility which renders the tissues less able to resist the at- tacks of the germs of suppuration. Morbid Anatomy.— 1. The seat is nearly always on one side; the extent is variable; sometimes there are several collections of pus, surrounded and kept in ^lace by adhesions. 2 The exudate is purulent and may be very large in quantity, The condition of the lung is the same as in pleurisy with serous exudate. Symptoms.—The symptoms are those of serous pleurisy, and, in addition, the evidences of pus formation, high temperature, sweats, exhausdon and emaciation. Physical Signs.—The physical signs are precisely similar to those of serous pleurisy. Sometimes an external opening forms and a fistula results. Diagnosis.—The diagnosis can only be made with certainty by aspiration. Prognosis.—The prognosis is usually bad without treatment, but favorable with proper management. Results—1. Perforation, and discharge of pus— (1) through thoracic walls ; (2) through abdominal walls ; (3) into a bronchus ; % PRACTICE OF MEDICINE. 105 (4) into the abdominal cavity, colon or stomach ; rarely into the pelvis of the kidney. 2. Necrosis of one or more ribs. 3. Cheesy or calcareous degeneration of the exudate. 4. Collapse of the chest wall after the discharge, with recovery. Treatment.—1. To improve the general health and sustain strength by nourishing food and stimulants. 2. Aspiration and withdrawal of pus may be tried in the case of children. 3. Free opening in the scapular line, with thorough and con- tinuous drainage. 4. Wasliing out the chest with a mixture of compound tincture of iodine and water (one part to four). 5. In old cases the excissiou of a part of tlie chest zvall so as to allow the chest wall and lung to approach each other and heal more readily. Pneumothorax. Definition and Synonyms.—An accumulation of air in the pleural cavity. It is also called pyo-pneumothorax and Jiydro-pueumothorax, be- cause the entrance of air with the germs in it sets up inflammation and leads to the formation of an exudate, serous or purulent in character. Causes. — 1. PlitJiisis is 'the most common cause. A cavity opens into the pleural cavity and allows the entrance of air. 2. An injury, which causes an opening into the pleural cavity. 3. Emphysema, the entrance of air being due to the bursting of an enlarged air vesicle. 4. Empyema, which bursts into a bronchus. Morbid Anatomy.— 1. The possitiou of the lung is changed, so that it occupies the upper back part of the thorax, and is col- lapsed. 2. The changes in tJie pleura are those of inflammation. Symptoms.— 1. Sudden and extreme dyspnoea from the col- lapse of the lung. 2. Collapse from the general shock. 3. If life is prolonged, fever, exliaustion and dropsy occur from pus formation. Physical Signs. — 1. On inspection, the chest js found to be u io6 PRACTICE OF MEDICINE. enlarged on the affected side, and the respiratory movements are absent. 2. On palpation vocal fremitus is absent. On percussion there is tympanitic resonance over that part of the chest containing an excess of air and flatness over the lower part where the fluid is. 4. On auscultation there is an absence of all respiratory sound except at the upper back part of the chest where there is bronchial breathing over the collapsed lung ; succussion causes metallic tinkling. Diagnosis.—It is distinguished from—1. Empyema, by the sudden occurrence and the tympanitic resonance above the level of the fluid. 2. A pht/iisical cavity, by the cavernous respiration and the gradual formation of a pulmonary cavity. Prognosis.—The prognosis is almost always unfavorable. Re- covery may occur from closure of the opening. Treatment.—The treatment consists in relieving pain by mor- phia, quebracho and hot applications to the chest. Hydrothorax. Definition.—A collection of fluid in the thoracic cavity not due to inflammation. Causes.—1. Venous hypercernia from any cause especially dis- ease of the mitral valve. 2. Bright's disease. Symptoms.— 1. The appearance of the patient is striking; there is pallor and cyanosis and it is difficult or impossible for him to lie down, because the abdominal viscera will push against the dia- phragm and still farther hir.der the action of the heart and lun^s. 2. Dyspnoea occurs in greater or less degree from the pressure on the lungs. 3. The pulse is small and rapid from the pressure upon the heart and vessels which prevents them from being properly filled. Physical Signs.—Absence of respiratory movement and ot vocal resonance, flatness on percussion and absence of respiratory sound over the lower part of the chest where the fluid is. Diagnosis.—It is distinguished from—1. Pleurisy with serous effusion by the fact that pleurisy occurs only on one side and hydrq- thorax on both, PRACTICE OF MEDICINE. 107 2. Pulmonary oedema by the liquid rales in oedema and the ab- sence of respiratory sound in hydrothorax. Prognosis.—The prognosis depends on the nature of the pre- vious disease. The fluid can usually be readily removed, but so long as the cause persists is liable to return. Treatment.—i. To remove the fluid by (i) hydragogue cathar- tics, such as the saline purgatives, elaterium, &c; (2) diuretics and diaplwretics ; (3) aspiration which is certain and very little dangerous. 2. To improve the general Jiealth by tonics, &c. Pulmonary Phthisis. ( Phthisis—Pulmonary Consumption—Pulmonary Tuberculosis.) Definition.—An inflammatory affection of the lungs, caused by the bacillus tuberculosis, and characterized by a great tendency to caseation and softening, or by the formation of connective tissue. The course is chronic and the disease one of the most frequent known. Causes.—I. The bacillus tuberculosis is the essential cause. (See Tubercle and Tuberculosis for description and favorable con- ditions for the development of this germ.) 2. A certain predisposition, which may be (1) hereditary, (2) ac- quired. Nothing is known of the nature of the hereditary predis- position. The acquired predisposition is brought about by (a) bad hygie- nic conditions, especially dampness and over-crowding; (b) bron- chitis and catarrhal pneumonia; (c) pleurisy ; (d) pregnancy and lactation ; (e) diabetes ; (/) typhoid fever; (g) measles. Most of these predisposing causes act by lowering the vitality of the tissues ; pleurisy acts by lessening the freedom of the chest movements, and thus permitting the germs to remain in contact with the bronchioles or alveoli. Morbid Anatomy.—i. The primary seat of pulmonary phthisis is in the apices of the lungs. 2. The histological changes are— , (1) accumulation of epitlielial cells in the alveoli of the lungs from desquamation of the alveolar epithelium ; the cells are granular and fatty from the action of the leucomaines; (2) the exudation of fibrinous material and leucocytes into the alveoli (see Inflammation); ioS PRACTICE OF MEDICINE. (3) cellular infiltration and thicJcening of the alveolar walls and the walls of terminal bronchioles from the exudate of leucocytes and their conversion in part into connective tissue ; (4) increase of inter-lobular connective tissue, from the exudate of leucocytes and the formation of connective tissue therefrom. 3. The extent of these changes varies ; usually at first only one apex is involved, but the disease spreads till a large part or the whole of one lung is involved, and later the other is affected. Usually a large caseous mass is formed, or in very chronic cases of slight intensity there is a gradual increase of connective tissue till the whole lung becomes greatly indurated (fibroid phthisis); these morbid conditions may be combined in different degrees. 4. The bronchi are more or less inflamed in the catarrhal form of phthisis, and in the fibroid form may be greatly dilated from the contraction of the new formed connective tissue. Later Changes.— 1. The caseous mass may undergo one of three changes— (1) absorption ; (2) softening and discharge, with the formation of a cavity; (3) calcification—the calcified mass being surrounded by a wall of connective tissue. 2. In fibroid phthisis the gradual contraction of connective tis- sue causes depression of the chest zvalls, dilatation of the bronchi {bronchiectasis) and displacement of neighboring viscera. It results in hypertrophy and dilatation of the right side of the heart from the destruction of blood vessels in the lungs. 3. Cavities are formed by the softening and expectoration of caseous masses; their zvalls may be cheesy and rough or smooth and more or less firm; they are usually crossed by bands of con- nective tissue which contain blood vessels, and one or more bronchi project into them—being more resistent than the caseous mass; the contents of a cavity may be cheesy matter, pus or blood; the tissue around a cavity is consolidated and the pleura over it usually inflamed and thickened. Cicatrixation occasionally occurs alter the contents of a cavity have been discharged. Symptoms.—1. Respiratory. Cough, usually dry and hacking in the early stages and "loose" later on, occurs in all cases; it is prob- ably due to the irritation of the bronchial mucous membrane. Expectoration is scant at first and usually profuse at a later pe- riod in the caseous form. Scant in the fibroid form as a rule unless there is bronchiectasis. It is muco-purulent in character, often con- tains elastic fibers and nearly always contains bacilli. Dyspnoea is not usually marked except on exertion, because ol the gradual loss of breathing space and the simultaneous loss of flesh. Hemoptysis is frequent; the blood comes from the bronchial I PRACTICE OF MEDICINE. IO9 mucous membrane; it is scant and frothy in the early stages but later it may come from the rupture of a vessel in the cavity and be very profuse; it is bright red in color. Hoarseness and loss or voice may be present from laryngeal phthisis. 2. Temperature. More or less elevation of temperature is usually- present in the early stages, the afternoon temperature being about ioo° to 1010. At a later period there may be high fever from the absorption of septic matter contained in cavities. In such cases the fever is usually preceded by a chill and followed by sweating. 3. Circulatory. The pulse is quick and weak from the loss of strength. 4. Nervous. There is usually remarkable cheerfulness. Pain is not a prominent symptom, but may be present from accompa- nying pleurisy. 5. Digestive. Anorexia is marked, even in the early stages, and nausea and vomiting are frequent at a later period. Diarrhoea may occur from a complicating intestinal tuberculosis. 6. Urinary. Albuminuria may occur from tubercular nephritis. 7. Cutaneous. Pallor occurs early, as a rule, and is prominent. It is probably due to the action of the tubercle bacilli in prevent- ing the formation of red corpuscles or actually destroying them. (Edema occurs in the late stages from defective nutrition of the walls of the vessels and poor quality of blood, and sometimes from thrombosis of a vessel. Night sweats are exceedingly common ; no satisfactory explan- ation can be given of their occurrence. 8. General. Emaciation and loss of strength are usually pro- gressive, and are due probably in part to the direct action of the germs and in part to the fever. Physical Signs.—The physical signs depend on the form. In the catarrhal form there are three stages—1st, that of commencing formation of tubercles ; 2d, that of consolidation (caseation) ; and 3d, that of cavity formation. The fibroid form is far more chronic in course and does not usually lead to the formation of cavities. The physical signs of the two forms will therefore have to be considered separately. A. Catarrhal phthisis. 1st stage—Incomplete consolidation. 1. On inspection, there may be (1) slight depression at the apex of the lungs from consolidation of some of the air cells at that point; (2) less movement than natural in respiration for the same reason. 2. On palpation, there may be slight increase in vocal fremitus at the apex because the lung is more solid than normal. 3. On percussion, slight dullness for the same reason. 4. On auscultation, (\) broncho-vesicular respiration ; (2) increased vocal resonance from increase of solid matter in the lung ; (3) pro- 110 PRACTICE OF MEDICINE. longed expiration, from loss of elasticity of air cells; (4) crackling, from slight pleuritic friction or from slight bronchitis. 2d stage—Complete consolidation. 1. On inspection, some changes as in 1st stage, but more marked. 2. On palpation, vocal fremitus increased, unless (1) there is a layer of fluid between lung and the cnest will, (2) the bronchus leading to the consolidated spot is closed, or (3) there is a consid- erable thickness of healthy lung tissue over the consolidated spot. 3. On percussion, dullness of greater or less degree, because the lung is solid and contains little or no air. 4. On auscultation, (1) bronchial breathing unless prevented by the conditions which may prevent vocal fremitus (q. v.); (2) rales from bronchitis, pleurisy or breaking down of caseous mass. 3d Stage.— Cazrity. 1. On inspection—same as in 2d stage. 2. On palpation. (1) vocal fremitus increased if layer of consoli- dated lung around the cavity, but may be absent; (2) rhoncal frem- itus from the bursting of bubbles in the cavity. 3. On percussion, (1) dullness, if consolidated lung is around the cavity; (2) cracked-pot sound, if the cavity communicates with bronchus by a small opening; (3) tympanitic resonance, if the cavity has firm walls and the patient's mouth is open during percussion; (5) flatness, if the cavity is filled with fluid; (6) normal resonance, if healthy tissue surrounds the cavity. 4. On auscultation. (1) Caz'ernous or amphoric breathing, if the cavity is large and empty; (2) cavernous zvJiisper; (3) coarse bub- bling or gurgling rales from the passage of air through the fluid in a cavity. B. Fibroid phthisis— 1. On inspection, (1) the size of the chest is more or less dimin- ished ; often it is greatly contracted ; (2) the movements are much less free than normal ; both changes are clue to the formation and contraction of connective tissue. 2. On palpation, (1) the vocal fremitus is usually increased unless the pleura is greatly thickened or the bronchus is closed ; (2) the position of the heart's beat may be changed from the change in size and position of the lungs. 3. On percussion, dullness over the lung when there is increase of connective tissue, and increased resonance or tympanitic resonance over other parts from compensatory emphysema. 3. On auscultation, bronchial breathing unless the pleura is great- ly thickened or the bronchus is occluded. Diagnosis.—The essential point in the diagnosis of tuberculo- sis from all other affections, is the presence in the sputa of the baci li of tuberculosis. PRACTICE OF MEDICINE. Ill I. From bronchitis it is further distinguished by the fact that bronchitis occurs at the same time in both lungs, the rales are usu- ally coarser and more extensively distributed, and there is no dull- ness on percussion. 2. From pleurisy it is distinguished by the dullness (not flatness) on percussion, and by the further fact that tuberculosis usually begins at the apex. (A dry pleurisy, however, is often tubercu- lous). Prognosis.—The prognosis is always serious, but recovery may occur from (i) calcification of the tubercular mass, or (2) its dis- charge with subsequent healing of the cavity. The circumstances influencing the prognosis are— 1. Age. Elderly persons usually have fibroid phthisis, which runs a much slower course than the catarrhal form. 2. Heredity. The more decided the hereditary taint the more serious the prognosis. 3. Bad hygienic surroundings, and complications render the prog- nosis grave. Treatment.—A. Prop/iylactic.— 1. Children of a phthisical mo- ther should not be nursed by her, but by a healthy wet nurse, or they should be fed on pure milk. 2. Young persons with phthisical tendencies should live much in the open air, and should have a liberal diet. B. Hygienic. Pure air, warm clothing and a nutritious diet are essential. C. Climatic. The desirable features with respect to climate are (1) freedom from germs, (2) freedom from dampness, (3) sufficient warmth to allow the patient to spend much of the time in the open air. The favorite resorts in this country are Colorado, the Adiron- dacks, California, Asheville, N. C, South Carolina, Florida, and Thomasville, Ga. D. Medicinal.— I. To improve the general health and sustain strength by cod liver oil, arsenic, the hypophosphites and alcohol. 2. To reduce fever by phenacetine and quinine. To allay cough by codeine, chloroform, and other agents of this class. 4. To prevent night szveats by atropia, ergot or agaricine. 5. To relieve haemoptysis by ergot, cupping, absolute quiet, &c. E. Antiseptic treatment has given poor results. Creosote, car- bolic acid, iodoform, and bichloride of mercury have been given internally; of these, creasote seems to have done some good. In halations of creasote and carbolic acid have also been employed. Injections of iodine or carbolic acid into the lungs, and the incision and drainage of cavities have not given good results. The use of Koclis lymph (tuberculine) has not up to this time. I 12 PRACTICE OF MEDICINE. (April 2d, 1891) been followed by satisfactory results, so far as treatment is concerned, and the reaction from the treatment- chill and fever—is sometimes very severe, and has repeatedly caused death. CHAPTER IV. DISEASES OF THE DIGESTIVE SYSTEM. Stomatitis. Definition.—By stomatitis is meant an inflammation of the mu- cous membrane of the mouth. Varieties. — The varieties are—1. Catarrhal. 2. Ulcerative. 3. Aphthous or follicular. 4. Thrush. Catarrhal or Simple Stomatitis. Definition.—A superficial inflammation of the mucous mem- brane of the mouth characterized by redness and swelling. Causes.—1. Age. The disease is rather more common in chil- dren than adults, but may occur at any age. 2. Mechanical irritation by broken teeth, &c, is a frequent cause. 3. Chemical irritation by alkalies or acids or by spices or hot substances will also cause it. 4. Mercury when improperly administered will induce the affec- tion. 5. It occurs in certain infectious diseases, such as scarlet fever, small-pox, &c. 6. It may arise by extension from neighboring parts, such as the pharynx or nose. practice of medicine. 113 7. Defective cleanliness of the mouth in insane persons, or those who are delirious, may cause it by the retention of pieces of food. Symptoms and Signs.—1. Sensory. There is more or less pain in the mouth which is greatly increased by eating and especi- ally by acids or sweets. Usually there is a very unpleasant taste in the mouth. 2. Secretory. The secretion of saliva is greatly increased and is often mixed with tenacious mucus. The increased secretion is due to the increased flow of blood to the mucous follicles and sali- vary glands. 3. On inspection the mucous membrane is found to be reddened from the increased amount of blood in it and swollen and softened from the serous exudate, so that frequently it shows the prints of the teeth. Prognosis.—The prognosis of the affection is uniformly good and it rarely lasts more than a week or ten days. Treatment.—The treatment consists in : 1. The removal of the cause. 2. Thorough cleansing of the mouth by frequent washing with boracic acid or some other similar agent. 3. The relief of pain by the use of small pieces of ice or the use of bland fluids such as milk or cream or some mucilaginous drink. 4. The use of astringents, such as myrrh in chronic cases. Ulcerative Stomatitis. Definition.—An inflammation of the mouth characterized by the formation of ulcers usually on the gums and about the teeth. Causes. — 1. Probably infection is the essential cause. It is sometimes epidemic among soldiers and in prisons. 2. Age. It is most common, perhaps, among poorly nourished children. 3. Debility and bad hygienic surroundings predispose to it. 4. It occurs in severe salivation from mercury. Symptoms and Signs.—1. Seat. The ulcers are usually sit- uated on the gums. 2. Pain is often quite severe, especially when eating. 3. There is a copious flow of saliva and mucus. 4. The glands of" the neck are usually considerably enlarged in consequence of the absorption by the lymphatics of the germs or leucomaines in the ulcers. 5. Fever somet/'mes occurs and debility is usually a, marked symptom, 15 ii4 PRACTICE OF MEDICINE. 6. On inspection the gums look red and swollen ; the teeth are often loosened, and ulcers with soft borders are seen. Prognosis and Duration.—Such cases nearly always end in recovery in ten days or two weeks. Rarely the bones become dis- eased and the case is more tedious. Treatment.—I. To insure cleanliness is of the first importance. Frequent washing of the mouth with diluted listerine (boracic acid) or salicylic acid or carbolic acid solution will accomplish this. 2. Chlorate of potash seems to be almost a specific in these cases; probably the chlorine it contains acts as a germicide ; it should be used as a mouth wash and a small quantity may be swal- lowed. Aphthous Stomatitis. Definition.—An inflammation of the mucous membrane of the mouth, characterized by the formation of white spots and subse- quently ulcers, chiefly on the buccal surface. Causes.— i. Age. It may occur at any age, but is more com- mon in children than in adults. 2. It is probably due to a germ, but as yet none has been dis- covered. Symptoms and Signs.— I. Sensory. The pain which these little spots cause is often excessive. 2. The secretion of saliva and mucus is usually increased. 3. On inspection, white spots varying in size from half a line to two lines in diameter are seen on the buccal mucous membrane or under the tongue. These spots consist of a fibrinous exudate in the most superficial layers of epithelium. After a time the white spots are replaced by a superficial ulcer. Diagnosis.—The disease is distinguished from thrush by the absence of the parasite mycoderma vini, which is characteristic of the latter disease. Prognosis and Duration.—The prognosis is always favorable and the disease rarely lasts longer than a few days. Treatment.—1. To relieve the pain of these little spots, espe- cially where an ulcer is formed, nothing is so efficacious as touch- ing them with a stick of nitrate of silver. 2. Cleanliness and disinfection of the mouth by means of fre- quent washing with a solution of borax or boracic acid, or carbol- ic acid, is essential to prompt relief and cure. PRACTICE OF MEDICINE. H5 Thrush. Definition.—An inflammation of the mouth, attended by the formation of white patches on the mucous membrane which are due to the presence of a parasite, the mycoderma vini. The dis- ease is extremely frequent. Synonyms.—Muguet, sprue. Causes.—1. The essential cause is the parasite or fungus men- tioned, the mycoderma vini. 2. Age. The disease is far more common among children than adults; indeed, it is very rare, except in infancy. 3. Artificial feeding and defective cleanliness are prominent causes. 4. It is far more common among weakly children than among vigorous ones. Symptoms and Signs.—1. On inspection, white spots may be observed upon the buccal mucous membrane or that of the tongue or gums. The fungus develops first in the middle layers of the mucous membrane and may cause considerable ulceration. 2. Pain on eating or attempting to nurse is so great that the little patients are nourished with difficulty. 3. There is usually a considerable flow of saliva and mucus. 4. Debility is nearly always a prominent symptom in severe cases. Prognosis and Duration.—Except in the case of very feeble children, recovery usually occurs in a week or two. Death oc- curs sometimes in the case of very weakly children. Treatment.— 1. Thorough cleansing of the mouth and the bot- tle (in the case of "bottle-fed" children), is of the first importance. 2. Germicides, such as boracic acid or carbolic acid in solution, are useful. Borax or boracic acid is most commonly used. 3. Nourishing food is essential in view of the debility which is nearly always present in these cases. Rectal alimentation may be resorted to in extreme cases. Noma, or Cancrum Oris. Definition.—A gangrenous affection of the jaws. It is very rare. Causes.—The essential cause is probably a germ. It occurs in children usually and especially in those who are surrounded by bad hygienic conditions and are debilitated. I l6 PRACTICE OF MEDICINE. Symptoms and Signs.—The disease first appears as a little black spot on the inner side of one cheek. It rapidly spreads un- til nearly the whole cheek becomes gangrenous. The neighbor- ing glands are greatly enlarged and there is high fever from the absorption of septic matters. Prostration is usually extreme. Prognosis and Duration.—The disease nearly always termi- nates in death and rarely lasts longer than two weeks. Treatment. —The treatment consists in destroying the dis- eased tissue by caustics; the use of antiseptics and the adminis- tration of nutritive food stimulants and tonics. Glossitis. Definition and Frequency.—By glossitis is meant inflamma- tion of the tongue; the disease is very rare. Causes.—It may be caused by the sting of a bee or wasp, and occasionally it occurs without any obvious cause. Symptoms, and Signs.—The chief sign is a great szvelling of the tongue ; it may be so great as to interfere with respiration ; it usually projects from the mouth. The swelling and tension cause great pain and swallowing is very difficult. There is a copious flow of saliva and the glands of the neck are enlarged. Prognosis and Duration.—The prognosis is favorable and the disease rarely lasts longer than a few days. Treatment.—When the tension is great free incisions should be made to relieve pain, and lessen the swelling. Painting with cocaine solution gives great relief. ' The strength should be sustained by suitable diet. Pharyngitis. Definition.—An inflammatory affection of the mucous mem- brane of the pharynx and tonsils. It may be acute or chronic. Varieties of the acute form.— i. Catarrhal or simple. 2. Follicular tonsilitis. 3. Abscess of the tonsils. • PRACTICE OF MEDICINE. 117 Catarrhal Pharyngitis. Definition and Frequency.—An acute inflammation of the mucous membrane of the pharynx, the exudate being catarrhal in character. It is the common "sore throat." Causes.—1. Sudden chilling of the body when overheated or exposure to a draft is the most common cause. 2. Mechanical irritation, such as operations upon the pharynx or injuries to it. 3. Chemical irritants, such as swallowing concentrated acids or alkalies. 4. Acute infectious diseases, such as scarlet fever and small-pox. 5. Infective. Severe attacks of "sore throat" sometimes oc- cur among students who are dissecting or exposed to septic in- fluences. (Hospital sore throat.) Symptoms and Signs.—1. Sensory. Pain is always present to a greater or less extent; it is often severe. 2. Deglutition is not only painful, but more or less difficult. 3. The voice is somewhat affected, having a muffled sound, " as if the mouth was full." 4. Secretory. The flow of mucus and saliva is at first dimin- ished, but subsequently becomes decidedly greater than normal. 5. Constitutional. The temperature is usually elevated, in severe cases rising to 1030 or 1040. Other constitutional symptoms are headache, backache and aching in the limbs. On inspection the pharynx looks red and somewhat swollen, and is usually partially covered with a muco-purulent exudate. Prognosis and Duration.—The prognosis is uniformly favora- ble and the attack usually ends in three or four days. Treatment.—The treatment consists in—1. The reduction of inflammation by the administration of Dover's powder, hot foot baths, and hot applications to the throat, all of which dilate the vessels of the skin and lessen the congestion of the throat. 2. The administration of chlorate of potash, which probably acts as a germicide and destroys the germs which caused or keep up the inflammation. 3. The relief of pain by cocaine spray if the pain is intense, or by poultices to the neck in less severe cases. Follicular Tonsillitis. Definition.—An inflammatory affection of the pharynx, in which the tonsils are chiefly involved, the inflammation being con- fined chiefly to the follicles of those glands. n8 PRACTICE OF MEDICINE. Causes.—The causes are the same as those of simple catarrhal pharyngitis. Symptoms.—The symptoms are also like those of acute pha- ryngitis, except that on the tonsils are seen little zohite spots which are due to the accumulation of secretion in the follicles. Some- times the secretion is spread over the tonsil so as to look like a false membrane. Diagnosis.—This white matter on the tonsils differs from a diphtheritic membrane, however, in being readily removed, and not fibrous in character. The Prognosis and Duration are like those of pharyngeal ca- tairh. The Treatment does not differ from that of acute pharyngitis. Abscess of the Tonsils. Definition.—Frequency and synonym. This affection, sometimes called parenchymatous tonsillitis or epiinsy, is an inflammation of the tonsil glands leading to suppuration in their substance. It is of common occurrence. Causes.—I. Catarrhal pharyngitis. 2. Rheumatism is supposed by many to be a cause. 3. Some people have repeated attacks. Symptoms.—1. Sensory. The pain is extreme and szvalloz^nne is very difficult. 2. Speech is very much impaired on account of the difficulty of using the muscles of the palate. 3. There is a secretion of glairy mucus in large quantities. 4. Constitutional. The temperature is considerably elevated (1030 or 1040), and there is great prostration. Headache and loss of appetite are also prominent symptoms. 5. Inspection of the tonsils is difficult on account of the inabili- ty of the patient to open his mouth well. The tonsils, usually one, but both may be involved, are greatly swollen; hard at first but soft when pus has formed. There is decided swelling on the out- side also. Prognosis.—The prognosis is usually favorable; suffocation has occasionally occured from bursting of the abscess into the throat and the escape of pus into the windpipe. Duration.—The abscess usually bursts or is ready to open in four or five days. PRACTICE OF MEDICINE. II9 Treatment.—1. To relieve pain, cocaine in the form of spray is by far the most efficacious remedy. Poultices to the throat sometimes give partial relief. A spray of menthol, 20 parts, to olive oil, 80 parts, is highly spoken of. 2. Cutting into the abscess with a guarded bistoury is indicated so soon as softening occurs. Enlarged Tonsils. Causes.—1. Age. Hypertrophy of the tonsils is far more com- mon in children than in adults. Symptoms and Signs.—The tonsils project, from their in- creased size, into the cavity of the pharynx. Persons with enlarged tonsil usually snore loudly and the voice is rather husky. Hearing may be impaired from pressure on the posterior nares. Prognosis.—The prognosis is always favorable as to life. Treatment.—Medical. Iodine and ergot applied locally sometimes effect a cure. Excision of the tonsils is the best treatment. Chronic Pharyngitis. Definition.—Chronic inflammation of the mucous membrane of the pharynx. It is an exceedingly common affection and is frequently called "clergyman's sore throat." Varieties.—1. Simple, in which the mucous membrane looks somewhat swollen and thickened and fljod vessels may be seen running over it. 2. Granular, in which the mucous membrane is not c>nly thick- ened, but numbers of little granules, enlarged follicles, are to be seen upon it. 3. Dry pharyngitis, in which the membrane has a peculiar glazed look. 4. The hypertropliic form in which the pharyngeal glands are enlarged so as to form little protuberances on the posterior wall of the pharynx. Causes.— I. Climate. A climate characterized by sudden changes of temperature is very apt to cause or keep up chronic pharyngitis. Dampness is especially injurious. 2. Occupation. Any occupation which exposes a person to dust of any kind is a cause. A sedentary life, especially in over- 120 PRACTICE OF MEDICINE. heated rooms, is also a cause. Public speaking is such a common cause that one of its synonyms, clergyman's sore throat, is derived in this way. 3. Alcohol used habitually to excess is a very potent cause. 4. Smoking or staying in close rooms, such as inns, when others are smoking is a very common factor in the production of this disease. Symptoms and Signs.—1. Sensory. Pain is not usually present, but a feeling of discomtort and tickling is almost constant in most cases. 2. The voice may be somewhat impaired, and sometimes decided hoarseness is present. 3. The secretory symptoms vary; the amount of secretion is usually slight and quite tenacious; occasionally dry, brown crusts may be seen on the posterior wall of the pharynx. 4. The physical signs on inspection were mentioned under varieties. Diagnosis.—The diagnosis presents no difficulties. Complications.—Hearing is occasionally affected from an ex- tension of the inflammation to the eustachian tube, or pressure on the mouth of the tube by an enlarged gland. Laryngeal complica- tions sometimes arise. Prognosis.—The prognosis as to life is good; as to recovery not good, as a rule. Treatment.—The treatment is directed to : 1. The removal of the cause. A change of climate when practi- cable is very useful. Alcohol and tobacco should be abandoned. Rest to the voice is essential. 2. The removal of secretion is effected chiefly by sprays ; a solution of borax is very efficacious. 3. The correction of the pathological changes. When there are enlarged vessels on the posterior pharyngeal wall the local use ol iodine and ergot is useful; a spray of boracic acid or of carbolic acid also acts well. Other agents are solution of nitrate of silver or chloride of zinc in water or tannic acid in glycerine. In the dry form when stimulation is indicated a spray of men- thol 20 parts to olive oil 80 parts is very useful. If there are en- larged glands th 3. To allay irritability bismuth and lime water, tincture of iodine, hydrocyanic acid, morphia and other drugs are useful. Mustard plasters over the stomach are very efficacious. Chronic Gastritis. Definition and Synonyms.—A chronic inflammation of the mucous membrane of the stomach. It is called also chronic gastric catarrh and imflammatory dyspepsia. Causes.—t. Ancemia and debiliby are predisposing causes of great importance. An insufficient supply of blood to the stomach causes a diminution in the amount of hydro chloric acid secreted and weakness of the muscular coat. , Debility, however produced, also causes weakness of the muscular coat. The diminution of hydro- chloric acid and defective movements of the stomach cause the food to ferment and to set up inflammation of the stomach. practice of medicine. 123 2. In gout and BrigJtfs disease there is a retention of excre- mentitious matters in the blood which may cause gastritis. 3. Mechanical hyperemia, from disease of the liver, heart or lungs, causes gastritis, by interfering with the formation of hydro- chloric acid and by interfering also with the proper nutrition of the mucous membrane of the stomach. 4. Alcohol, spices and highly seasoned food act as direct irri- tants Morbid Anatomy.— 1. The exudate and mucus form a tena- cious muco-purulent coating on the stomach. 2. The structural changes are most marked near the pylorus. Pigmentation is always present to a greater or less extent from the destruction of the red blood corpuscles thrown out and broken up at the spot. The mucous membrane always contains more connec- tive tissue formed from white blood cells (see Passive Hyperaemia). The cells lining the tubules are usually in a state of fatty or granu- lar degeneration, and the mucous follicles may be atrophied from pressure of the new connective tissue, or cysts may be formed from closure of their mouths. Sometimes the connective tissue grows very luxuriantly in spots, forming a " mammulated " appearance ; occasionally superficial ulcers are formed. Symptoms.—1. Digestive. Nausea and vomiting are frequent, es- pecially in drunkards. The vomited matters are acid from the presence of lactic and butyric acids formed by fermentation. They contain much tenacious mucus and "sarcinae ventriculip and eructations are frequent. The fermentation which causes the formation of acid is due to (1) want of hydro-chloric acid, (2) the coating of the food with tenacious mucus which interferes with digestion. There is usually little or no appetite and much thirst. The. bowels are usually constipated. 2. Cardiac. Palpitation of the heart and a feeling of oppres- sion are common, from distension of the stomach with gas and re- flex action through the vagus. 3. Nervous. Headache, dullness and mental depression are conspicuous symptoms, and are probably due to the absorption of the products of fermentation or decomposition of the food in the stomach. Pain in the stomach is not usually very pronounced, but there is some tenderness on pressure. Urinary. The urine is usually scant, alkaline, and contains phosphates, probably in consequence of the diminution in the quantity of normal acid generated by the stomach. Diagnosis.—From atonic dyspepsia chronic gastritis is distin- guished by the tenderness over the stomach and the presence of the causes of the latter affection. It should be remembered, how- ever, that atonic dispepsia, by causing fermentation of the contents of the stomach, will set up gastritis. 124 practice of medicine. Prognosis.—The prognosis depends on the cause. If that can be removed recovery may be expected, and not otherwise. Treatment. —The indications of treatment and means of ful- filling them are—I. To rcmoz>e the cause. Diet is of the utmost importance. Alcohol and all highly seasoned food should be scrupulously avoided, and milk, eggs and bland soups should be used. Starchy food is injurious as well as sweet things, because they readily ferment. Digitalis is useful in heart failure, and saline catliartics will tem- porarily relieve the mechanical hyperaemia to some extent. 2. To allay irritability, by means of sub-nitrate of bismuth, small doses of opium, hydro-cyanic acid and other sedatives. In very severe cases, zoashing out the stomach gives more relief than anything else. 3. To improz>e the, general health by the administration of strych- nine, iron, the vegetable bitters, &c. Life in the open air is of great service. 4. To improve digestion and relieve annoying symptoms, hydro- chloric acid is useful in all cases. It prevents fermentation and pro- motes digestion directly. Strichnine is useful also in improving digestion by increasing the flow of gastric juice and stimulating the muscular coat. To prevent the formation of gas, tincture of iodine, carbolic acid or salicylic acid may be employed. For heartburn, magnesia and aromatic sptrits of ammonia arc use- ful. Alkaline mineral waters have a very beneficial effect in many cases. Cancer of the Stomach. Frequency and Varieties.—The stomach is a frequent seat of cancer. The most common variety of the disease in this organ is scirrhus, but soft cancer also occurs. Causes.— 1. Age. The disease is very rare before forty and occurs most frequently after fifty. 2. Sex seems to have no influence in cancer of the stomach (Strumpell). 3. Heredity is an undoubted cause in a large proportion of cases. Morbid Anatomy.—1. Seat. The pylorus and lesser curva- ture are usually involved. 2. Characteristics. The size of the tumor varies ; it is usually hard, contracted and nodular, and in the later stages ulcerates. Symptoms.—1. Digestive. Vomiting is common, the vomited matters frequently containing some blood, but copious haemateme- sis is rare. The amount of free hydrochloric acid in the gastric juice is greatly diminished, or none may be found. practice of medicine. 125 2. Nervous. Pain is present in nearly all cases; it often comes on after eating, but may occur at other times; there is usually some tenderness. 3. The general symptoms are emaciation, exhaustion and cacJiexia, which is of great importance in diagnosis. 4. Usually a tumor can be felt, and unless this can be done the diagnosis must be doubtful. Diagnosis.—It is diagnosed from ulcer by the existence of a tumor and the marked cachexia. Haematemesis is usually much greater in ulcer than in cancer. 2. From chronic gastric catarrh it is distinguished by the ab- sence of a history pointing to this disease, the presence of a tumor, the cachexia and the character of the vomited matters. 3. It is distinguished from an aneurism when pulsation is com- municated to the tumor from the artery behind it by lifting the tu- mor or pushing it to one side when the pulsation ceases. Prognosis.—The prognosis is uniformly bad. The duration is from six months to three years. Results.—Results are— 1. Stenosis of the pylorus and consequent dilatation of the stomach. 2. Extension to surrounding parts. 3. Ulceration into the peritoneal cavity, or outwardly through the abdominal wall (rarely.) Treatment.—The treatment is chiefly palliative and consists in the administration of opiates or other analgesics and of bland food. Surgical measures—removal of the pylorus and attaching the duo- denum to the stomach or attaching the small intestine to a heal- thy part of the stomach have been practised, but with unsatisfactory results. Ulcer of the Stomach. Definition and Synonyms.—An ulcer through the mucous coat of the stomach, which may extend through the muscular and serous coats. It is sometimes called simple ulcer or round ulcer. Causes.— 1. Age and sex. It is most common in women be- tween the ages of fifteen and thirty-five. 2. Ancemia and clilorosis are causative conditions 3. The essential cause is a digestion of the stomach wall by the gastric juice. The presence of alkaline blood prevents this in health, but if from any cause, as (1) injur}', (2) hemorrhage, (3) plugging of a small vessel, the circulation is stopped at any point, digestion of that part occurs and an ulcer is the result. Morbid Anatomy.—1. Characteristics of tJie ulcer. There is us- 126 PRACTICE OF MEDICINE. ually but one which is nearly always on the lesser curvature of the stomach, is round in shape, from half an inch to three inches in di- ameter, and is funnel shaped—the wide end of the funnel being at the mucous surface, the narrow end at the peritoneal. 3. Condition of the surrounding tissues. The surrounding tis- sues are infiltrated and hard from the formation of connective tissue. 4. Condition of the peritoneum. The overlying peritoneum is thickened and has undergone an adhesive inflammation by which the stomach has beceme adherent to some adjacent organ—the pancreas, liver, colon, diaphragm, &c. 4. Mode of healing. When healing occurs cicatricial tissue is formed and there is very great contraction. Symptoms.— 1. Nervous. Pain and tenderness are among the most trequent symptoms of gastric ulcer. The pain is usually .vorse immediately after eating, and is often very severe. It is located in the region of the stomach, but often radiates to the back. The ten- derness is usually over a limited area (the ulcer.) 2. Digeslr.e. There are the usual symptoms of chronic gastric catarrh, but in addition there is in nearly all cases a history of one or more attacks of copious hcematcmesis. Diagnosis.— 1. From Cancer of the stomach, q. v. 2. From chronic gastric catarrh it is distinguished by the great- er pain and tenderness and the haematemesis in ulcer. 3. From gastralgia by the occurrence of haematemesis and the time at which the pain usually appears after taking food. In many cases, especially when there has been no hemorrhage, the diagnosis of ulcer of the stomach cannot be made with certainty. Prognosis.—Death occurs in about 50 per cent of the cases; the causes of death are (1) hemorrhage; (2) exhaustion; (3) peri- tonitis. Results.— 1. Healing may occur with contraction. 2. Stricture of the pylorus decurs, and consequent dilatation of the stomach, if the cicatrix is at the pylorus. 3. Abscesses in the walls of the stomach occasionally occur. 4. Hemorrhage is extremely common, and may cause death. 5. Perforation may occur into the peritoneal cavity, pleural cav- ity, or into the intestinal canal; or the liver may be involved and an abscess result. Treatment.—1. Rest to the stomach is absolutely essential. Rectal alimentation should be resorted to for some weeks, if pos- sible ; then small quantities of peptonized milk or meat may be given by the mouth. 2. To allav irritability and relieve fain, subnitrate of bismuth in teaspoonful doses three times a day, should be employed; morphia and cocaine are also useful; phenacetine and the allied substances PRACTICE OF MEDICINE. 127 may also be used with advantage. In some cases, when feeding by the mouth is essential, zvashing out the stomach once a day is very beneficial. 3. To check hemorrhage, opium is the best remedy. Perfect quiet in the recumbent position should be enjoined. Dilatation of the Stomach. Frequency.—Dilation of the stomach sufficiently great to cause trouble is rare. Causes.—There are three classes of causes—1. Obstruction of the pyloric orifice, from— (1) simple stricture; (2) cancer; (3) outside pressure from tumors, &c. 2. Increased pressure within the stomach, from— (1) habitual over-eating; (2) fermentation and the formation of gas. 3. Weakness of tJie muscular walls of the stomach, from— (1) chronic gastric catarrh ; (2) general debility. Morbid Anatomy.—i. Situation of the stomach. Nearly al- ways the stomach is dragged down lower than natural in the ab- dominal cavity by its own weight. 2. Size. The size of the organ is greatly increased, and it may hold as much as seven pints of fluid. (Fagge). Symptoms and Signs.— i. Digestive. The digestive symp- toms are, in the main, those of chronic gastric catarrh and the causa- tive affection. The vomiting of very large quantities of liquid with pieces of food taken some days before is characteristic. 2. On inspection, palpation and percussion, the lower border of the itomach is found below the umbilicus, and there is a marked full- ness on the left side of the abdomen. Diagnosis.—The diagnosis is based on : 1. The situation of the stomach. 2. The size of the stomach as measured by (1) the amount of fluid which is vomited out or can be pumped into it; and (2) the distance to which a stomach tube will enter; the tube passes usually in the case of a normal stomach tzoo feet from the lips. Prognosis.—The prognosis depends upon the cause. In can- cer it is of course unfavorable. A simple' stricture may some- times be dilated, inside pressure may be lessened or removed and the walls may be toned up. The prognosis is doubtful, however, in all cases. Treatment.—1. To remove the cause when practicable is the first thing to_do. 128 PRACTICE OF MEDICINE. 2. To zoash out the stomach and thus remove fermenting sub stances is more useful than anything else for obvious reasons. 3. Strychnine, ergot and electricity have been used to tone up the muscular coat and cause contraction of the stomach. Gastralgia. Definition.—Synonyms and frequency. By gastralgia is meant pain in the region of the stomach, usually occurring in paroxysms of great severity and not connected with inflammation or other lo- cal condition. Causes -It is most frequent in young zoomcn, and especially in those of nervous temperament. Sometimes it seems to be due to cold. Anaemia seems to be a cause. Symptoms—There is no digestive symptom. The pain usu- ally occurs in paroxysms often weeks or months apart, but some- times ever)- day or several times a day. The pain is sharp and lancinating in character and may extend to the back. It has no connection with eating. Usually there is marked anaemia, and menstrual disturbances are common accompainments. Diagnosis—It is distinguished from (1) ulcer, by the absence of vomiting (as a rule) and especially by the haematemesis; from (2) cancer, by the absence of cachexia and the age of the patient; from (3) gastric catarrh, by the absence of vomiting or other di- gestive disturbances. Prognosis.—The prognosis is good. Treatment.—The treatment consists in improving the general health by cod liver oil, arsenic, strychnine and iron, and the ad- ministration of analgesics during the paroxysms. Hot applica- tions sometimes give relief. H.EMATEMESIS. Definition.—The vomiting of blood which was poured out in the stomach. Causes.— 1. Ulcer and cancer, q. v. 2. Obstruction to the portal circulation, as in cirrhosis of the liver. 3. The hemorrhagic diseases, purpura, &c. Symptoms.—If in large quantity and thrown up soon after it is piured out the blood is bright in color. If retained some time it looks like coffee grounds. Diagnosis.—It is distinguished from nose bleeding or bronchial Inm trrhagc by an examination of those parts. Prognosis.----The prognosis depends entirely on the cause. Treatment.—The treatment also depends in great measure upon the cause, but quiet is essential in all cases. Opium, gallic and tannic acid, ergot, turpentine and persulphate of iron have been given to check the hemorrhage. PRACTICE OF MEDICINE. 129 DISEASES OF THE INTESTINES. DlARRHCEA. Definition and Frequency.—An abnormal frequency of the discharges from the bowels, which are nearly always less consist- ent than in a state of health. It is of very common occurrence. Causes.—There are two general causes of diarrhoea.— 1. An excessive secretion or transudation of liquid into the bowels. 2. Excessive peristalsis of the bowels, which forces out their contents before the liquid portion can be absorbed. Excessive secretion may be due to—1. Nervous influence, as fright or anxiety. 2. Inflammation. 3. The action of certain drugs (saline cathartics). Excessive peristalsis may be due to— 1. Nervous influence, irre- Lpective of inflammation. 2. Inflammation, and increased reflex irritability in consequence. Symptoms.—The symptoms attendant on diarrhoea need but little notice here. The character of the discharges depends on the cause of the attack and the part of the bowel affected. Other matters in connection with dirarhcea will be considered in connection with the different diseases of which it is a symptom. Acute Intestinal Catarrh. Definition, Synonyms and Frequency.—An acute inflamma- tion of the mucous membrane of the intestines. It is of very com- mon occurrence, and is known a*"enteritis" "catarrhal enteritis, "acute diarrhoea," &c. Causes.—1. Season of tlie year. Attacks of acute diarrhoea are more fequent in the summer and autumn than at other seasons, probably because most germs find favorable conditions for develop- ment then and because the diet at those seasons is liable to be irri- tative in character. . . .. , 2. Improper food and drink, such as unripe fruit, diseased meat, impure drinking water, &c, are common causes; the irritating substances which they contain are apt to cause inflammation. 3 Exposure to cold and dampness or to extreme heal may cause acute intestinal catarrh. Cold and wet probably act by forcing the blood from the surface. The action of heat is not understood: it is probable that it only acts indirectly by facilitating the growth of germs and the formation of noxious substances in the food and water (Fagge). 17 130 PRACTICE OF MEDICINE. 4. Constipation often alternates with diarrhcea and causes the latter condition by irritating the mucous membrane of the bowels. 5. The eruptive fevers often cause diarrhoea. (See Acute Infec- tious Diseases for explanation). Morbid Anatomy.—1. Scat and extent of bowel involved. Usually a catarrhal enteritis affects the lozver part of the small intestine and the upper part of the colon. Diarrhoea occurs in such cases. The duodenum alone or the duodenum and adjacent parts may be involved ; in such cases diarrhcea does not occur and jaundice is a frequent complication. 2. Structural changes. The usual changes in inflammation of a mucous membrane are present—redness, swelling, enlargement of the glands, albuminoid degeneration of the lining cells, ulceration in severe cases. 3. Secretion and exudate. The secretion of mucus is increased from increased afflux of blood and from mucoid degeneration of the cells and this is mixed with the serous exudate and cells which have passed out of the vessels and the epithelial cells which have desquamated. Rarely in very severe cases the exudate may be fibrinous in character and lead to more or less extensive necrosis of the mucous membrane. Symptoms.—I. Digestive. Diarrhoea is the most striking symptom in those cases which involve the colon. It is due to (1) increased secretion and exudate and (2) increased irritability of the nerves leading to more rapid peristalsis. The discharges are liquid in character and contain no mucus which is separate from the faecal matter. Constipation occurs in those cases where the inflammation is limited for the most part to the duodenum because the flow of bile is impeded and there is consequent diminution of peristalsis. More or less jaundice is common in such cases. Nausea may occur from absorption of morbid products or from a simultaneous affection of the stomach. Flatulence from decompo- sition of food is of common occurrence. 2. Nervous. Pain and tenderness are present in nearly all cases, but are rarely severe. The pain often comes on just before an action on the bowels and the patient is easy in the intervals. 3. Temperature. The fever is rarely high, but as a rule there is some elevation of temperature. Diagnosis.----1. From dysentery enteritis is distinguished by (i) the absence of tenesmus; (2) the absence of free mucus or blood in the actions. 2. From poisoning it is differentiated by the history of the case and the greater gravity of the symptoms as a rule in cases qf poi- soning. PRACTICE OF MEDICINE. 131 3. From typhoid fever by the absence of an enlarged spleen and the difference in the course of the fever. Prognosis.—The prognosis is nearly always good in acute enteritis. Complications.—1. Jaundice. 2. Inflammation of the stomach. Treatment.—1. The diet should be mild and unstimulating. Rest in bed is important for speedy recovery. 2. To remove offending matters when present, purgatives, such as calomel or the salines, are useful. 3. To relieve pain, to allay inflammation and to cJieck discliarge, opium and bismuth, salol and the alkalies, such as bicarbonate of soda or aromatic spirits of ammonia are the best remedies. After the acute stage has passed, astringents, tannic acid, catechu, kino, alum, &c, may be employed to check discharge. Phlegmonous Enteritis. Definition and Frequency.—A rare disease characterized by inflammation of serous and muscular coats of the intestines. Causes.—Intussusception and strangulation of the bowels are the most usual causes. Rarely there is no obvious cause. Morbid Anatomy.—Extreme congestion and discoloration of the serous coat, along with softening and serous exudation into the muscular coat, constitutes the morbid anatomy. Symptoms.—Extreme pain and tenderness, nausea, vomiting, tympany and obstinate constipation, due to inflammation and con- sequent loss of tone of the muscular coat. Diagnosis from peritonitis is impossible; indeed it is a local- ized peritonitis. Prognosis.—Serious. Treatment. — Opiates, to relieve pain; saline purgatives, to empty the bowel, unless there is obstruction, when laparotomy is necessary. Chronic Intestinal Catarrh. Definition, Synonyms and Frequency.—A chronic inflamma- 132 PRACTICE OF MEDICINE. tion of the mucous membrane of the intestines. It is called also " chronic diarrhcea." It is of frequent occurrence. Causes.—i. Frequent attacks of the acute form. 2. Passive hyperaemia, as in cirrhosis of the liver and certain heart troubles. 3. Tuberculosis of the bozvels. 4. Waxy degeneration of the bowels. Morbid Anatomy. — 1. In the simple form, (not tuberculous or lardaceous), there are the usual evidences of chronic inflamma- tion of a mucous membrane, shaven beard appearance or pigmen- tation, increase of connective tissue with either atrophy of the mucous membrane or the formation of polypoid growths. Little cysts are sometimes formed from closure of the mouths of the fol licles and the accumulation of secretion in them. 2. In the tuberculous cases the glands, solitary and agminated in the lower end of the ilium and upper end. of the colon, are in- volved chiefly. Tubercles (q. v.) developed in them undergo casea tion and softening, and an ulcer is formed with infiltrated edges and which extends around the bowel. The mesenteric glands in these cases are nearly always enlarged and often caseous ; they may soften and burst or calcify. In zoaxy degeneration the changes are not marked. The mu- cous membrane of the intestine may look rather translucent and cedematous, and if iodine be poured over it a mahogany color is produced. Symptoms.—1. Digestive. Diarrhoza is the most common of the digestive symptoms. 2. Nervous. Pain is not usually present, or, at any rate, is not a conspicuous symptom. 3. In the tuberculous form emaciation is progressive and some- times becomes extreme. There are usually symptoms of tubercu- losis elsewhere also. 4. In cases of lardaceous degeneration in addition to the diar- rhoea there are usually evidences of waxy degeneration of the liver and kidneys. Diagnosis.—The diagnosis as to the cause of chronic diarrhcea is based on the associated affections, such as cardiac or hepatic trouble, tuberculosis of the lungs or waxy degeneration of the liver or kidneys. Prognosis.—The prognosis depends upon the cause, but is usually very serious. Treatment.— 1. To remove the cause if possible is the first in- dication. 2. Diet and dress are very important; the diet should be bland PRACTICE OF MEDICINE. 133 and nutritious (milk, eggs, &c.,) and flannel should be worn next the skin to avoid chilling. 3. To cJieck tlie discharge—bismuth, tannic acid, persulphate of iron, nitrate of silver, opium and many other remedies have been employed and may be tried with hope of amelioration if not cure. Cholera Morbus and Cholera Infantum. Definition and Frequency—A disease characterized by pro- fuse vomiting and purging, great prostration, and in adults by cramps in the legs, &c. It is quite common. Causes.—1. Season.—It is far more common in hot weather than in cold. 2. Fatigue and debility are predisposing causes. 3. Sudden chilling of the body when over-heated may induce an attack. 4. Improper food, especially in the case of children, is a very prominent cause. Attacks of milk poisoning or ice cream poisoning are due to the formation of tyrotoxicon in the milk by the action of germs (Vaughan). It is probable that the essential cause is always a germ. Morbid Anatomy.—There is generally no morbid change apparent. Gastro-enteritis is occasionally found. Symptoms.—1. Digestive. Sudden and violent vomiting and purging at first of the contents of the stomach and bowels and then of liquid. Great thirst. 2. Nervous. Pain in the belly and cramps in the legs are always present in adults. 3. Circulatory. The pulse becomes rapid and weak and may be imperceptible; the skin is cold and clammy. 3. General. Prostration is extreme, especially in cases of chol- era infantum and the anterior fontanelle in the case of infants is sunken. Diagnosis.— 1. From Asiatic cJtolera it is distinguished by the absence of the comma bacillus from the discharges and the spo- radic character of the disease. 2. In irritant poisoning the symptoms are usually more persist- ent than in cholera morbus, and blood is vomited, and discharged by the rectum. Prognosis.—The prognosis in the case of adults is nearly al- ways favorable. 134 PRACTICE of medicine. In children the disease (called cholera-infantum in them) is ex- tremely dangerous. Treatment.—In adults, counter-irritants, hypodermic injections of morphia and stimulants should be employed. In children, counter-irritants, stimulants, heat to the extremities, and lastly fresh air, are of great importance. Cholera infantum is very liable, if the immediate danger is pre- vented, to run into a chronic catarrh of the intestinal canal. Intestinal Catarrh of Children. Definition, Synonyms and Frequency.—An inflammatory af- fection of the mucous membrane of the bowels. It is also called entero-colitis and sometimes improperly cholera infantum. It is of great frequency, especially in crowded cities and in hot weather Causes.— I. The essential cause is probably a germ or a num- ber of germs of different character. 2. Age. It occurs usually in children between the ages of six and eighteen months, but may occur earlier or later. The influenceof age is explained by (i) the fact that before six months most children use breast milk and (2) after two years of age the tissues of the intes- tines seem to be more resistant than they are at an earlier period. 3. Heat. The vast majority of cases occur in hot weather for two reasons. A temperature of 6o° throughout the day greatly facilitates the action of germs and the formation of leucomaines (tyrotoxicon) and furthermore heat is terribly depressing to the child and renders its tissues less resistant. 4. Overcrozvdiug is a potent factor because it causes debility and renders the child an easier prey to any disease. 5. Improper food is the most direct and common cause. Milk which has undergone a change resulting in the formation of tyro- toxicon is in the majority of cases responsible for the disease. Morbid Anatomy.— 1. Seat and extent. The part of the bowel usually involved is the lower part of the ileum and the upper part of the colon. This is probably due to the fact that there is a par- tial stagnation of faecal matter in this part of the intestine so that the germs have an opportunity to do mischief there. (See lecture on Bacteria) 2. Contents of the bozvel. The contents of the bowel consist of aecal matter, mucus, epithelial cells, pus cells and serum, some- times blood. The mucus in the large bowel is often very tenacious. 3. Structural changes. The vessels are distended and the mu- cous coat of the bowel is swollen in consequence of the exudate of practice of medicine. 135 serum and leucocytes. The follicles are enlarged and softened and may be pigmented; at a late stage they ulcerate. Symptoms. — i. Digestive. Diarrhcea is the first and most prominent symptom; the actions vary in number and character. They may be white from absence of bile ; they may be green ; they often contain little white masses of either fat or casein; rarely they contain blood and mucus (dysenteric stools.) Tenderness is almost always present to some extent and fain is a common symp- tom. Tympanites frequently occurs. Vomiting is usual and often persistent. Thirst is sometimes a very troublesome symptom. The tongue is coated with a white fur and is red at the tip and edges in the early stages, but if exhaustion comes on it becomes brown and dry. 2. Nervous. Sleeplessness and restlessness. At a later stage convulsions and stupor. Pain in the belly has already been men- tioned. 3. Circulatory. The pulse is rapid and soon becomes feeble ; the skin is pale and in protracted cases there is swelling of the feet and ankles from cardiac weakness. 4. The temperature is elevated from 1010 to 1040; but if pros- tration occurs it may fall below normal (collapse.) 5. General. Pallor, emaciation and prostration are due to the loss of nutritive material in consequence of the diarrhea and the defective absorption by the inflamed mucous membrane. Diagnosis.—The cerebral symptoms may be mistaken for those of acute hydrocephalus. In the latter disease the bowels are con- stipated, the face flushed usually and the anterior fontanelle pro- minent ; the reverse is the case in infantile entero-colitis. Prognosis.—The prognosis depends, in great measure, on the possibility of moving the child to the country and changing its food supply. The disease is always serious and prompt measures are necessary. Treatment.—A. Prophylactic. Pure air, pure milk and proper hours of feeding are best prophylactics. The child should be taken to the country if possible. The milk (when bottle fed) should be sterilized. > B. Remedial. The objects of treatment are—I. To destroy germs and check fermentation by calomel, bismuth, salol, naphtha- lin, resorcine, &c. 2. To remove morbid matters from the stomach and bowels by purgatives (rarely advisable) and irrigation ot the stomach (?) and bowels. 3. To allay pain and restlessness by opium and paraldehyde and by warm or cool baths. 4. To cluck discharge by bismuth, opium, catechu, &c. 5. To sustain strength by stimulants and proper food. i36 PRACTICE OF MEDICINE. Typhlitis and Peri-typhlitis. Definition, Synonym and Frequency.—An inflammation in and around the caecum and vermiform appendix. It usually com- mences in the latter part and is frequently called " appendicitis." The disease is not very common. Causes.— I. Ulceration or bursting of the zurmiform appendix from— (i) the irritation of a foreign body ; (2) impacted and hardened faeces ; (3) tubercle; (4) distension from catarrhal inflammation ; (5) possibly injuries. 2. Rarely the disease begins as inflammation of the caecum. Morbid Anatomy.— 1. Changes in the appendix are either ul- ceration or distension with catarrhal exudate (Fitz). 2. Changes in the surrounding tissue are— (1) localized peiitonitis, with or without peritoneal abscess; (2) inflammation with serous or purulent exudate in the sur- rounding connective tissue. 3. Changes in the muscular and mucous coats consist in infiltra- tion with fluid and cells. Symptoms.—1. Digestive and nervous. Pain and constipation are the prominent symptoms. The pain may not be felt at first in the region of the caecum, but tenderness soon appears. Nausea and vomiting are frequent. 2. The temperature is elevated from ioo° to 1040 or 105°. 3. General. Chills, fever and sweats often occur, if pus is form- ing. Exhaustion and emaciation also occur under similar circum- stances. Physical Signs.—1. On inspection, the thigh on that side is frequently found to be flexed to prevent pressure and pain. 2. On palpation and percussion, dullness and a tumor may be detected in the right inguinal region. Diagnosis.—The diagnosis is based on (1) the history of the case, (2) the seat of the swelling, (3) the existence of fever. Prognosis.—About 74 per cent, recover (Fitz). The chief cause ot death is (1) peritonitis from ulceration of the appendix di- rectly into the peritoneal cavity, or the formation of an abscess which bursts into it, (2) exhaustion. Results.—Resolution occurs in about 26 per cent, of cases treated medically. 2. The appendix may ulcerate directly into the peritoneal cavity. * practice of medicine. 137 3. Abscess may form, and if not opened, may burst (1) into the abdominal cavity, (2) into the intestinal canal, (3) into the bladder or pelvis of the kidney, (4) outwardly through the abdominal wall. 4. Recurrence occurs in about 40 per cent, of the cases. Treatment.—1. Medical. Rest, opiates, poultices, enemeta. 2. Surgical. Laparotomy and removal of appendix in case of urgent symptoms with or without a tumor. Intestinal Parasites, or Worms. Varieties.—The most important are—1. Tape, or taenia solium. 2. Round, or ascaris lumbricoides. 3. Thread, or seat worms. Tape and round worms are found in the small intestine ; thread worms in the rectum. Causes.—1. Age. Most commo in children ; tape worms occur in adults. Modes of Infection. — 1. Meat or vegetables (uncooked). 2. Impure water, containing ova of worms. Symptoms.— 1. Anaemia and debility (rare symptoms) from the withdrawal of blood by parasite (anchylosfcoma duodenalis). 2. Obstruction of bowels (rare). 3. Local irritation, pain, diarrhoea, &c, frequent symptoms. 4. Reflex—convulsions, strabismus, &c, not common. Diagnosis.—Based on sigJit of the worms ; round worm eight to twelve inches in length ; thread worm three-quarter inch or one inch; tape worm, in flat segments, one-third to three-quarter inch in length. Prognosis.—Usually favorable. Death may occur from (1) obstruction, (2) entrance into larynx, (3) convulsions. Treatment.—A. Propliylactic. 1. Pure water. 2. Clean utensils and cleanliness generally. 3. Thorough cooking. B. Medicinal. For tape worms, kousso, pomegranite, male fern, chloroform, croton oil and pumpkin seed. For round worms, santonin, calomel and turpentine. For thread worms, enemeta of quinine, aloes or gentian. 18 i38 practice of medicine. Trichinosis. Definition.—An affection characterized by digestive disturb- ances and great pain and stiffness of the muscles, the symptoms being due to the action of a parasite—the trichina spiralis. Causes.—The only cause is the ingestion with raw or very rare meat, (pork) of the trichina spiralis. Morbid Anatomy.—I. The intestines are usually inflamed by the action of the parasite which | is liberated when the pork is digested. 2. The parasite is about one twenty-fifth of an inch long when first liberated, but grows to about one sixth of an inch in length and then discharges a great number of living young ; the young parasites pass out ot the bowel and reach the muscles. 3. The muscles most affected are the diaphragm, the muscles of the throat and the intercostal muscles. They are inflamed and many parasites are found in them coiled up and surrounded by an oval capsule formed chiefly of connective tissue. Symptoms.— 1. Digestive disturbances. Pain and diarrhcea are common. 2. Nervous and muscular. Violent pain and stiffness in the mus- cles and sometimes paralysis occurs. 3. The temperature is elevated to 1010 or 1060. 4. There is szveating and oedema. Diagnosis.—The diagnosis is based on an examination of a small piece of muscular tissue obtained by cutting or harpooning. Prognosis.—The prognosis is uncertain. Treatment.—Propliylactic is most important. Glycerine, pic- ric acid and other remedies have been used, but with little success. Constipation. Causes.—1. Defective power of the muscular coat of the in- testines from (1) debility; (2) want of nerve power (3) chronic ca- tarrh of the bowels; (4) chronic peritonitis. 2. Deficient secretion from (1) want of proper nerve power; (2) atrophy of mucous follicles (simple chronic catarrh); (3) abuse of purgatives. Morbid Anatomy.—1. Dilatation of the bowel from distension with faecal matter and gas. 2. Ulceration of the bowel from contact with hardened or de- composing faecal masses. Accompanying "Symptoms.—1. Pain in the bowels and flat- ulence, from irritation of the bowels by hardened faeces and decom- position and fermentation of retained masses. practice of medicine. l39 Furred tongue and bad taste in the mouth, from absorption of excrementitious substances. 2. Nervous disturbances—headache, dullness, stupor, &c, from retention of morbid matters. 3. Respiratory disturbances, from pressure of distended bowels on the diaphragm, and possibly from reflex action and influence of retained leucomaines. 4. Cardiac and circulatory disturbances, caused just as the re- spiratory. Prognosis.—Good, unless the cause cannot be removed, and the case is of very long standing. Treatment.—Diet. Branny food, fruits, vegetables and water, (especiaUy before breakfast), to increase secretion. 2. Exercise, electricity, massage, &c, to increase the power of the muscular coat. 3. Certain medicines (to be avoided if possible^) such as (1) strych- nine, and possibly ergot, to strengthen the muscular coat, and (2) aloes, cascara, salines, belladonna, &c, to increase the secretion. 4. Enemata of water, &c, to move the bowels mechanically (not advisable). v Enemata of glycerine, or glycerine suppositories, to cause a flow of water into the lower bowel and to set up slight irritation (very useful). Dyspepsia, or Indigestion. Definition and Frequency.—A disturbance of the function of digestion without obvious pathological change in the digestive or- gans. Causes.__1. Anything which impairs the quality of the di- gestive fluids, such as (1) anaemia and debility, (2) defective nervous action, (3) sedentary habits. ; 2. Anything which impairs the pozver of the muscular coat of the bowels, such as those conditions just named, and in addition (1) the pressure of tumors, (2) adhesions and sclerosis of the bow- els from former inflammation, (3) torpor of the liver, or deficiency of the bile, from any cause. Symptoms.—1. Digestive, such as (1) heart-burn, (2) disten- sion with gas, (3) regurgitation of food from fermentation and the formation of acids and gases, (4) sometimes vomiting from irrita- tion of the stomach by fermenting food, (5) constipation from weak- ness of muscular coat of the bowels, or (6) diarrhcea from the irritation of fermenting food catarrh. 140 practice of medicine. 2. Nervous disturbances, such as (i) sleepiness, (2) stupor, (3) headache, (4) disturbances of vision, &c, from the absorption of leucomaines, and probably also from defective action of the liver, which usually acts as a filter. 3. Cardiac and respiratory disturbances, from pressure on dia- phragm by distended bowels. 4. Urinary. Deposit of phosphates and oxalates from defective nutrition and want of acid. Diagnosis.— 1. Distinguished from Gastric catarrh, by the ab- sence of stringy mucus in the vomited matter and the absence of tenderness. 2. Cardiac disease, by temporary character of symptoms and absence of physical signs. Results. — Chronic gastric catarrh, unless dyspepsia is relieved. Prognosis depends on cause and duration — usually good. Treatment.—1. To stimulate secretory and muscular coats of the stomach and bowels by (1) exercise, (2) massage, (3) strych- nine, (4) bitters, (5) alcohol, (6) emetics, &c. 2. To supply substances for formation of gastric juice, such as pepsin and hydrochloric acid, or of pancreatic secretion, such as ex- tract of pancreas and bicarbonate of soda. 3. To relieve special symptoms, such as — (1) heart-burn, by ammonia and alkalies ; (2) flatulency, by peppermint, or camphor and ammonia, for immediate relief, or by tincture of iodine, salicylic acid, carbolic acid, salol, &c, when a more lasting effect is desired. (3) constipation, q. v. Acute Peritonitis. Definition.—An acute inflammation of the peritoneum. Varieties. —1. Local. 2. General. Causes. — 1. Diseases of some abdominal viscus, such as (1) ulcer of the stomach, or duodenum, (2) ulceration of the bowels, as in typhoid fever, (3) typhlitis and appendicitis, leading to per- forative ulceration. If perforation of the gut does not occur the inflammation will probably be adhesive and localized; if perforation does occur it is usually purulent and generalized, because faecal matters and germs pass into the peritoneal cavity in two large amount to be disposed of by leucocytes; (4) intestinal ob- struction. practice of medicine. 141 2. Disease of some pelvic organs, such as salpingitis, &c, in which germs may pass along the genital canal and tubes to the peritoneal cavity, or a pyo-salpinx may burst into the peritoneal cavity. 3. Extension of localized peritonitis rarely causes an attack of generalized form. 4. Injuries, which admit germs to the peritoneal cavity. 5. Certain acute, infectious diseases, such as erysipelas, septicae- mia, diphtheria, &c, and — 6. Certain chronic diseases, as Brighfs : in both the latter classes of affections the disease is probably due to the circulation of mor- bid materials in the blood and lymph vessels. Rheumatism is an occasional cause. Morbid Anatomy.—1. Redness and loss of lustre occur from the increased amount of blood in the vessels, and albuminoid de- generation of the endothelial cells. Desquamation of endothelial cells occurs from loss of their vitality and the action of the serous exudate. 2. The exudate may be serous, purulent, fibrinous or hemorrhag ic; in severe cases it is chiefly purulent; in the localized form fibrinous and adhesive. 3. The muscular coat is swollen from the exudate of serum and leucocytes, and there is consequent loss of tone and tympanitic distention. 4. If recovery occurs there is great increase of connective tissue and more or less extensive adhesions. Symptoms.—1. Onset usually sudden because of ulceration of a hollow viscus and sudden discharge of its contents; it may be gradual. 2. Position in bed—on the back, with limbs flexed on the ab- domen because of— 3. Pain and tenderness, which is due to inflammation. No men- tal disturbance usually. 4. The digestive symptoms are (1) vomiting, probably reflex, (2) tympanites, and (3) constipation, from loss of tone of the muscular coat of the bowels. 5. The temperature is elevated (from ioi° to 1050), especially in septic cases from absorption of leucomaines. 6. Respirations shallow and rapid, from distension of abdomen and pain caused by rubbing of peritoneal surfaces against each other in deep inspiration. 7. The pulse is small and hard and rapid, from reflex action through the vagus probably, but the cause is not clear. 8. Frequent desire to pass water from reflex irritation, and later retention from inflammation and loss of power of the muscular coat of the bladder. 142 practice of medicine. Diagnosis.—It is distinguished from (i) colic, by fever and the increase of tenderness on pressure in peritonitis ; from (2) enter- itis, by constipation and excessive tenderness. Prognosis.—Very bad in the generalized form ; usually good in localized and adhesive form, which is protective. Results.—1. Death in a large proportion of cases from (1) shock, (2) exhaustion, (3) septic poisoning. -> Recovery occasionally in purulent form after (1) absorption of pusf'^) encapsulation and calcification, (3) discharge externally through umbilicus, vagina, bowel, bladder, &c. Treatment.—1. To give rest to the bowels and relieve pain by (1) avoidance of purgatives, (2) opium, (3) belladonna, (4) turpen- tine stupes, (5) poultices. 2. To sustain strength, by rectal enemata when the stomach is intolerant. . f 3 Laparotomy and washing out abdomen with closure of opening when hollow viscus has burst, or removal of tubes in salpingitis. Laparotomy to be considered also in all cases of purulent peri- tonitis. ... 4. Salme purgatives are of doubtful value in medical cases. Chronic Peritonitis. Definition.—Chronic inflammation of the peritoneum. Varieties.—1. Simple. 2. Tubercular. 3. Cancerous. Causes of simple form often unknown. Bright's disease is a frequent cause. The tubercular form is due to tubercle bacilli. It may occur at any age ; is common in women, and especially common in negroes. It frequently extends from the Fallopian tubes, but the tubes are as often affected secondarily. The cancerous form is of course due to cancer and the irritation caused by it. The tubercular is by far the most common variety. Morbid Anatomy.—1. Tubercles may be found distributed over the peritoneum in great numbers (acute miliary form). 2. Theie may be caseous and ulcerating masses, which may form openings between the different coils of intestines; or the glands (mesenteric) may be chiefly involved, enlarged and caseous. 3 There may be great increase of connective tissue (fibroid form,) causing contraction of the mesentery, coiling and shortening of in- testines and folding of omentum to form tumor-like mass. practice of medicine. 143 Symptoms.—1. Often latent. 2. Ascites, from serous exudate. 3. Tympanites, from loss of tone of the muscular coat of the bowel. 4. The Temperature may be elevated but is often sub normal ; , , the reason is unknown. 5. Pigmentation of face, &c, is often marked. Physical Signs.—1. On inspection there may be enlargment from (1) ascites, (2) encysted effusion, (3) omental thickening, (4) adhesions of coils of intestines, (5) enlarged mesenteric glands 2. Palpation and percussion give evidence in the same direction. Diagnosis—Tubercular tumors are distinguished from cancer- ous by (1) the existence of tubercular disease elsewhere, (2) possi- bly sub-normal temperature in tuberculosis, (3) cancer is rare in the young, tuberculosis common. Tubercular tumors are distinguished from ovarian tumors with great difficulty by (1) the existence ot tuberculosis elsewhere than in the abdominal cavity, (2) the temperative disturbances common in tuberculosis, rare in ovarian tumors. Complications.—(1) Salpingitis, (2) pleuritis, (3) pericarditis all of which may be due to direct extension of the baccilli, (4) pulmo- nary phthisis, (5) intestinal tuberculosis. Prognosis.—Recovery sometimes occurs, but death is most common termination. Treatment.— 1. Medical. To sustain strength by food, stim- ulants, cod liver oil, ,&c. (See Pulmonary Phthisis.) 2. Surgical. Laparotomy and drainage have given encouraging results. Ascites. Definition and Frequency.—An accumulation of fluid in the peritoneal cavity. It is of frequent occurrence. Causes.—1. Any impediment to the portal circulation such as (1) cirrhosis of the liver, (2) thrombosis of the portal vein and pyle- phlebitis, (3) pressure on the veins by tumors, &c. 2. Diseases of the heart and lungs leading to passive hyperaemia. 3. Chronic peritonitis, simple or tubercular. 4. Cancer of the peritoneum. 5. Brigfifs disease. M4 practice of medicine. Morbid Anatomy. — i. Enlargement of the belly from the fluid which it contains. 2. Sodden and cloudy appearance of the peritoneum from the action of the liquid. 3. Displacement of organs from pressure of fluid. 4. Various changes due to causative condition. (See Chronic Peritonitis, Cirrhosis of the Liver, &c. Symptoms.—1. Respiratory symptoms (dyspncea) arc usually most conspicuous ; they are due to pressure. 2. Circulatory. Palpitation of the heart occurs from the same cause; oedema of the lower limbs may occur from pressure on the veins; enlargement of the veins on the surface of the abdomen to form collateral circulation. 3. Digestive disturbances, dyspepsia and constipation from pres- sure. 4. Urinary symptoms (scantiness) are due usually to lowered blood pressure. Physical Signs.—1. On inspection, enlargement of the belly from fluid. 2. Enlargement of the surface veins on abdomen to form col- lateral circulation. On palpation, fluctuation from fluid. On percussion, flatness at the sides, resonance in front, as the patient lies on the back, because the fluid sinks to the lowest part; but adhesions may tie the bowels down to the back of the abdo- men so as to cause flatness in front (see Chronic Peritonitis). Diagnosis.—Distinguished from (1) an ovarian cyst, by flat- ness at sides, resonance in front, as a rule, and history of the case; (2) pregnancy, by absence of signs of pregriancy; (3) distended bladder, by use of the catheter and change of position of fluid when patient changes position; (4) colloid cancer of peritoneum by tapping; no fluid flows in colloid cancer. Prognosis depends on cause. Treatment.—1. To remove the cause, if practicable. 2. To remove fluid, by (1) hydrogogue cathartics, (2) diuretics, (3) diaphoretics, (4) aspiration. Aspiration is indicated whenever respiration is much interfered with. practice of medicine. 145 Hyperemia of the Liver. Definition Frequency and Synonym.—An excessive amount of blood in the liver. It is probably of common occurrence and is known as "Congestion of the Livery Varieties.—1. Active. 2. Passive. Causes.—A. Active Hyperaemia. 1. Over-eating and drinking, especially of highly-seasoned food and irritating (alcoholic) liquors, which increase the work to be done by the liver and cause irritant substances to pass into it. 2. Malaria. The leucomaines formed in this disease probably pass through the liver and cause irritation. 3. Heat. The disease is common in hot climates; the cause is not very evident. B. Passive hyperemia. 1. Any obstructive disease of the heart or lungs which leads to accumulation of blood in the venous system. 2. Any regurgitant disease of the heart leading to over-filling of the veins. 3. Pressure on the veins leading to the heart. 4. Weakness of the heart's action from any cause, debility, sedentary habits, &c. Morbid Anatomy. — 1. The size of the liver is increased, be- cause it contains more blood. 2. The color in the passive form especially is darker than nor- mal, because of the amount of venous blood in the organ. 3. In consistence the liver is at first softer than normal, because of the serous exudate into it, but subsequently becomes harder from the formation of connective tissue. 4. On section it is (1) pigmented from the deposit of the color- ing matter of the blood (see Passive Hyperaemia); (2) mottled (nutmeg liver) from the excessive amount of venous blood in the center of the lobules and the lighter color of the cells at the peri- phery of the lobules; (3) there is an increase of connective tissue around the hepatic veins in the centre of the lobules. Symptoms.—1. Those due to the causative disease such as cardiac troubles, respiratory disturbances, &c. (q. v.) 2. Those due to the failure of the liver to perform its functions, such as headache, dullness, stupor, &c, from retention of morbid matters. 3. Those due to the accompanying conditions, such as nausea and indigestion from gastric catarrh, slight jaundice from duodenal catarrh, hemorrhoids, &c. Physical Signs.—1. On palpation and percussion the liver is found to be enlarged from distension with blood and sometimes tender from the increased.sensibility of the nerves. 19 146 practice of medicine. Diagnosis based on the presence of the causes of the disease and the absence of symptoms of abscess, cancer, &c. Prognosis.—The prognosis depends on the cause; in active hyperaemia it is usually good; in passive, it is usually bad. Treatment.—To remove tlic cause in cases of A. Active hyperaemia by unstimulating diet, &c. B. Passive hyperaemia, by digitalis in failing compensation in heart troubles. 2. To lessen the engorgement of the portal system of veins and carry off poisonous substances lying in the stomach and intestines by calomel, salines, the sulphur waters, &c. 3. To stimulate the liver (?) by euonymus, podophyllin, muriate of ammonia, &c. (See Functional Disturbances of the Liver.) Peri-Hepatitis. Definition and Frequency.—An inflammation of Glisson's capsule of rare occurrence. Causes. — 1. Injuries. 2. New growths. 3. Syphilis. 4. Cold possibly. Morbid Anatomy.—Size. The liver is contracted because of the new formation of connective tissue on the surface of the organ and also in the trabeculae which run in from Glisson's capsule. Symptoms.—1. Pain and tenderness over the liver and slight fever from the inflammation. 2. Sometimes cough, from involvement of the diaphragmatic pleura. 3. Occasionally jaundice and ascites from compression of the common bile duct and veins by the new formed connective tissue. Physical Signs.—1. On palpation and percussion slight en- largement, possibly, at first, but contraction afterwards. 2. On auscultation, friction sounds are sometimes heard from the rubbing of the surfaces against each other. Diagnosis.—Distinguished from—1. Intercostal neuralgia by the presence of fever and the situation of the pain and tenderness; 2, pluerisy by the situation of the pain and friction sounds ; 3, hep- atic abscess by the absence of marked enlargement of the liver and of sweats and repeated chills which sometimes occur in abscess. Prognosis. —The prognosis is generally good. practice of medicine. 147 Treatment.—To relieve pain and subdue inflammation by rest, poultices, counter-irritants. In the case of syphilis, iodide of po- tassium should be employed. Interstitial Hepatitis. Definition, Synonym and Frequency.—Interstitial Hepatitis, or Cirrhosis of the Liver, is a disease characterized by a great in- crease in the amount of connective tissue in the liver and atrophy of its parenchyma. It usually runs a chronic course. Causes.— 1. Alcoliol is by far the most common cause; it is uncertain whether it causes atrophy of the cells first, and then an increase of connective tissue or whether the increase of connective tissue is the primary change, and the atrophy of the cells is due to pressure. 2. Highly-seasoned food and malarial poisoning are rare causes ; both act by setting up an irritation in the liver. 3. Syphilis unquestionably causes one form of cirrhosis. Morbid Anatomy.—1. The sise of the liver is at first greater than normal, because of the exudate of cells and fluid into it; but later it is small, owing to the contraction of the new-formed con- nective tissue. 2. Color, consistence and appearance. Its color is lighter (hence its name, cirrhosis), its consistence firmer, and its surface irregular (" hob-nailed"), from the increase of connective tissue. 3. On section, in (1) the early stages the liver is filled with leu- , oocytes ; (2) in the late stages there is a great increase of connective tissue formed from the leucocytes and an atrophy of the parenchy- matous tissue. 4. There is passive Jiypero?mia and its results in the organs con- nected with the portal system, because the portal vessels are com- pressed by the new formed connective tissue. Symptoms. — 1. Digestive. Anorexia, nausea and furred tongue, from the failure of the liver to remove waste products, and from the accompanying passive hyperaemia and congestion of the stom- ach and bowels. Constipation is usual from the diminution in the amount of the bile formed; but diarrluza may occur from the fermentation of food and the catarrhal enteritis caused thereby. jaundice sometimes occurs from pressure of the connective tis- sue on the bile ducts. Ascites almost invariably occurs from the compression of the portal vessels by the connective tissue and the consequent passive hyperaemia of the portal system and the transudation therefrom, V 143 practice of medicine. 2. Respiratory. Dyspnoea occurs from the distension of the abdomen with ascitic fluid. 3. Circulatory. Gastric and intestinal hemorrhage from the passive hyperaemia and enlargement of abdominal veins from col- lateral circulation. 4. Nervous. Apathy, depression, delirium, convulsions and so called " cholaemia," from the retention of substances which should have been excreted or acted upon by the liver. 5. Urinary. Decrease in the amount of urine from lowered blood pressure in the arterial system ; diminution in the amount of urea from destruction of hepatic parenchyma ; increase of urates and presence sometimes of leucine and tyrosine from the same cause. Physical Signs.—1. On inspection, enlarged veins on abdomen and caput medusae around umbilicus (collateral circulation), dis- tension of abdomen from ascitic fluid. 2. On palpation, fluctuation, from the presence of fluid, enlarged spleen, from passive hyperaemia; sometimes irregular surface of the liver can be felt. 3. On percussion, enlarged spleen and ascites (q. v.). Diagnosis. —1. Distinguished from fatty liver, waxy liver and cancer ot liver by the absence of enlargement. 2. From chronic peritonitis, by the history of alcoholic excesses in cirrhosis. Prognosis and Duration.—The prognosis is very bad, but not absolutely hopeless ; the duration is from a few months to sev- eral years. Treatment.—To remove the cause ; to forbid the use of alco- hol, spices and highly-seasoned food; the most suitable diet is milk. 2. To relieve congestion and pressure symptoms by hydragogue cathartics, diuretics, diaphoretics and tapping. Tapping, in some cases, if repeated often, will lead to arrest of the disease, or, at least, the arrest of the dangerous symptoms. 3. To relieve symptoms as they arise. Abscess of the Liver. Definition, Synonym and Frequency. An inflammation of the liver leading to the formation of one or more collections of pus. It is sometimes called suppurative hepatitis, and is of comparatively rare occurrence. practice of medicine. 149 Causes.—The lodgment of septic emboli (pyaemia). 2. Ulcerative disease of the bowels, such as dysentery, in which infective emboli may be carried to the liver through the portal system. 3. Heat; the disease is most common in hot countries, proba- bly because the conditions for germ growth are favorable there. Often no cause can be discovered. Morbid Anatomy.—1. Number. They may be single or multiple. 2. The size varies from a minute point to a sack which holds five or six pints. 3. Condition of the zvalls and surrounding tissue. The walls may be irregular and caseous, or in older cases a pyogenic mem- brane may be present. The surrounding tissue is inflamed. 4. Characters of the pus. It may be liquid and yellow, or brownish in color; it may be cheesy. Symptoms.—Often there are none. Usually, however, there are— 1. Digestive Nausea and indigestion from failure of the liver to excrete waste matters, occasionally jaundice from pressure on a bile duct. 2. Respiratory. Dyspnoea, if a large abscess presses upwards on the diaphragm. 3. Urinary. Absence or great diminution of urea and the presence of leucine and tyrosine from the failure of the liver to burn off the nitrogenous waste. 4. Nervous. Depression from retention of excrementitious matters; pain often, but not always, from localized peritonitis; hic- cough. 5. Occasionally chills, fever and sweats when pus is forn ing; but pus often forms insidiously. Physical Signs.—1. On inspection, there may be some promi- nence over the liver. 2. On palpation, a swelling can usually be felt and frequently fluctuation. 3. On percussion, the outlines of the swelling can be deter- mined. Diagnosis.— 1. From cancer of the liver it is distinguished by the history of the case and especially by aspiration. 2. From enlarged gall bladder by the situation and shape of the latter. 3. From sub-diaphragmatic abscess (localized peritonitis with suppuration) by the history of the case; the diagnosis here is ex- tremely difficult. Prognosis.—Always serious, but recovery may occur. Duration from a few weeks to several years. 150 practice of medicine. Results.— I. Death from (i) peritonitis (from bursting); (2) exhaustion. Bursting may occur into (1) peritoneal cavity; (2) plueral cavi- ty or bronchus; (3) intestines; (4) pelvis of the kidney, or (5) through the abdominal wall. 2. Recovery may occur from (1) bursting in favorable direction; (2) absorption ; (3J calcification. Treatment.—1. To relieve pain by opiates, phenacetine, hot poultices, &c. 2. To sustain strength by nutritious food and stimulants (when absolutely necessary.) 3. To evacuate the pus by (1) aspiration, which is but little dangerous, or (2) free incision and drainage, in which the liver should be fastened to the abdominal wall before the abscess is opened. Union may be obtained between the liver and abdominal walls by either (1) cutting down on the liver and stuffing the wound with carbolized gauze till adhesions have formed and then cutting into the liver, or (2) cutting down upon the liver, sezoiug it to the ab- dominal wall and opening the abscess at once. Acute Yellow Atrophy of the Liver. Definition and Frequency.—A very rare disease character- ized anatomically by atrophy of the liver and change in its color, and c'inically by severe nervous symptoms which usually terminate in death. The disease is probably an acute infectious one, but it is not certain. Causes.—Pregnant zuomeu between the ages of fifteen and thirty-five are most liable to the disease. Morbid Anatomy.— 1. The body is yellow from absorbed bile. 2. The liver is soft, small, shrivelled and reddish-yellow in color; the cells are fatty or granular and many have disappeared entirely. The spleen is enlarged; there may be fatty degeneration of the heart and kidneys. Symptoms.—1. Digestive. Anorexia, na-jsea and vomiting, and jaundice. 2. Temperature is elevated —1010 to 1030. 3. The pulse is rapid and feeble. 4. The urine contains very Utile or no urea, but a large amount of leucine and tyrosine. practice of medicine. 151 5. Nervous. Headache, stupor, delirium and often convulsions and coma, probably from the absorption of leucomaines. Physical Signs.—On palpation and percussion, the liver is found to be greatly reduced in size. Diagnosis based on the symptoms and course of the disease. Prognosis bad. Treatment.—Symptomatic. Pylephlebitis. Definition and Varieties.—An inflammation of the portal vein or its branches, which may be suppurative or adhesive. Causes.— 1. Suppurative form is chiefly extension from veins of the intestines, as in appendicitis or lodgment of an embolus. (See Abscess.) 2. Adhesive form. Cirrhosis and hepatitis, which compress the veins and interfere with their nutrition (See Thrombus in General Pathology.) Morbid Anatomy.—1. In septic form, suppuration and abscess. 2. In adhesive form thickening of the coats of the vessel from in- flammation and then the formation of thrombi. 3. Changes due to obstruction of the vein ; passive hyperaemia of the abdominal organs; splenic enlargement and ascites. Symptoms.— 1. Rapid ascites from sudden stopping of vein. 2. Enlarged spleen. 3. No jaundice. Diagnosis from cirrhosis based on sudden occurrence of the ascites and different history as to cause. Prognosis bad. Treatment.—Palliative and symptomatic. Amyloid Degeneration of the Liver. Synonyms and Frequency.—A rare disease of the liver, called also " lardaceous" and " waxy" degeneration. Causes.—1. Age and sex. Men between the ages of 20 and 50 are most liable to it. 2. Sypfiilis. 3. Suppuration, especially when bones are involved. 152 PRACTICE OF MEDICINE. Morbid Anatomy.— 1. The size is much greater than normal. 2. The consistence is firm, but it is brittle. 3. The appearance is smooth, and on microscopic examination the outlines of the cells cannot be found. Tincture of iodine poured over the cut surface causes a mahogany color. 4. The kidneys and bowels are usually involved also. Symptoms.—Not marked ; no jaundice ; no pain. 1. Weight and heaviness in abdomen from enlargement of the liver. 2. Diarrhoea, when the bowels are involved. 3. Albuminuria, when the kidney's are involved. (See Bright's.) Physical Signs.—On palpation and percussion, the liver is found greatly enlarged. Diagnosis.—Distinguished from fatty liver by accompanying albuminuria and the presence of the causes. Prognosis.—Unfavorable; duration often several years. Treatment.—1. Removal of cause. 2. Antisyphilitics, if syphilis is present. 3. Alkalies and iodide of iron. Fattv Degeneration of the Liver. Forms.— 1. Fatty infiltration. 2. Fatty metamorphosis. Causes.—(See Fatty Degeneration in General Pathology). Morbid Anatomy.—1. The size of the liver is greatly increased. 2. The color is yellower than normal, and the consistence is softer. 3. On section, the cells are distended with fat. Symptoms.—Not marked; no jaundice; no ascites; no pain. 1. Weight and fullness, from enlargement of the liver. 2. Possibly gastric catarrh. 3. Greasy condition of the skin, Physical Signs.—Those of enlargement of the liver. Diagnosis.—(See Waxy Degeneration). Prognosis.—Not serious; duration indefinite. Treatment.— 1. Dietetic. The avoidance of saccharine and starchy food; skimmed milk and lean meat are useful. 2. Active, out-of-door life, to increase oxidation. 3. Cold climate, for the same reason. PRACTICE OF MEDICINE. 153 Cancer of the Livfr. Varieties. — 1. Scirrhus. 2. Medullary. 1) primary; and 2) secondary to cancer elsewhere. Causes.—I. Age. After forty usually; it may occur earlier. 2. It is often scondary to cancer elsewhere, as in the stomach. Morbid Anatomy.—1. The size of the liver is greatly increased, usually ; the individual nodules of cancer vary from a very small size to the size of a hen's egg. 2. Appearances. There are usually white, depressed spots on the surface and in the interior of the liver, from contraction of the connective tissue stroma of the cancer nodules. Symptoms—Often obscure in the beginning. 1. Pain, emaciation and cachexia, as in cancer elsewhere. 2. Jaundice, occasionally, when a cancer nodule presses on the bile ducts. 3. Ascites, sometimes, from the compression of the portal vein by the cancer. Physical Signs.—On palpation and percussion, there is found an enlargement of the liver, usually hard and nodular (in scirrhus), but sometimes soft (in medullary form). Diagnosis.—Distinguished from abscess by the severe pain, ca- chexia and emaciation, but especially by the results of aspiration. Prognosis—Always unfavorable; duration usually about a year. Treatment.—Opiates, phenacetine, &c, to relieve pain. Hydatids of the Liver. Definition.—A cyst in the liver caused by the taenia echi- nococcus. Causes.—The entrance into the alimentary canal — from whence it passes to the liver—of the taenia echinoccoccus. It is taken with water contaminated with the excrement of dogs. Morbid Anatomy.—1. The size of the cyst varies from a mi- nute point to the size of the head. 2. The walls consist of several layers of homogeneous substance and an inner layer of cells from which daughter cysts may grow. Around the cyst is a wall of connective tissue. The fluid contains no albumin, but little hooklets from around the heads of the taeniae. 20 154 practice of medicine. The cyst may (i) burst; (2) suppurate; (3) undergo calcifi- cation. Symptoms.—Not characteristic; due to pressure on neighbor- ing organs. Physical Signs.—On palpation and percussion there is enlarge- ment and sometimes the hydatid thrill. Diagnosis based on aspiration and character of aspirated fluid. Prognosis and Duration.—Hydatids of the liver may last for years and are harmless except for complications. Treatment.— 1. Prophylactic. Consisting especially in the purification of the drinking water. 2. Remedial. (1) aspiration and injection with tincture of iodine succssful in about 60 per cent, of cases; but often fails to kill the hydatids; (2) free incision and drainage, as in abscess of the liver, usually very efficacious; Ii\m excision of the cyst and part of the liver has been prac- tised two or three times with success, but is still on trial. Functional Derangements of the Liver Causes.—1. Anything which interferes with the proper func- tions of the liver, such as (1) cardiac diseases ; (2) malaria ; (3) spe- cific fevers; (4) sedentary habits. 2. Overtaxing of the liver with improper quality or inordinate quantity of food. Symptoms.— 1. Nausea, vomiting, headache, &c, from defect- ive elimination of waste products. 2. Slight jaundice, constipation and flatulence, from diminished discharge of bile. Treatment.—1. Dietetic. Simple food, as skimmed milk, fresh meat, &c. 2. Blue mass and calomel, salines, &c, to wash out the bowels and possibly prevent formation of ptomaines. Jaundice. Definition and Synonym.—Jaundice, or icterus, is the yellow color of the skin and other tissues, produced by the circulation of bile or biliary coloring matter in the blood. practice of medicine. 155 General Causes.—It is usually due to some obstruction to the outflozv of bile, and such obstruction may be i. Plugging of the common bile duct by tough mucus, swell- ing of the mucous membrane or gall stones. 2. Pressure on the duct from without by cancerous masses, connective tissue (in cirrhosis or perihepatitis), &c. Sometimes, however, there is no obstruction of the duct which can be discovered. In these cases the jaundice is called hoemato- genous. In hoematogenous jaundice it was formerly thought that the liver failed to remove bile from the blood ; this view has, of course, been abandoned, but no explanation of cases of haemato- genous jaundice has yet been found. It is probably due to a rapid destruction of red blood cor- puscles. Catarrhal Jaundice. Definition.—Jaundice due to catarrhal inflammation of the bile ducts. It is a common affection. Causes.—I. Gastro duodenal catarrh often causes it by exten- sion to the bile ducts and consequent swelling of the mucous mem- brane, and also by the formation of tough mucus. 2. Structural diseases of the liver, which cause hyperaemia from obstruction of the veins. 3. Any other impediments to the return circulation, such as cer- tain heart or lung troubles. 4. Syphilis, which probably causes catarrhal inflammation by the pressure of a gumma on a vein. 5. Pyaemia, the action of which is obscure. 6. Gall stones, which set up irritation mechanically. 7. Possibly exposure to cold. Morbid Anatomy.—1. The skin and other tissues are yellow from deposition of biliary coloring matter. 2. The bile ducts are swollen, red, and covered with muco-pus. 3. The liver is enlarged and yellow, and the gall bladder is en- larged and full of bile. Spmpfcoms. — 1. Yellowness of the skin, sclerotic, &c, from absorption of biliary coloring matter into the blood and its subse- quent deposit in the tissues. 2. Nausea and vomiting, from the retention in the blood of waste products or leucomaines. Clay-colored stools, constipation and flatulence, sometimes diarrhoea, from the absence of bile from the intestines. 3. The urine is brown, and on addition of nitric acid to biliary 156 practice of medicine. urine in a saucer, there is a play of colors where the two fluids come together. 4. The pulse is slower than normal, probably from the action of retained matters on the inhibitory apparatus. 5. The temperature is normal or possibly below normal. 6. The nervous symptoms are headache, apathy, vertigo, &c, and are due to the absorption of leucomaines or the retention of waste products. Violent itching is usual, and is probably due to the irritation of the terminal filaments of the nerves by the bile. Physical Signs.—1. On inspection, jaundice. 1. On palpation and percussion, sometimes there is slight en- largement from the accumulation of bile, and also slight tender- ness. Diagnosis. — 1. From cancer, by the absence of pain and ca- chexia. 2. From gall stories, by the absence of colic. Prognosis.—In simple catarrhal jaundice uniformly good, un- less there is obstruction from gall stones, &c. Treatment. — 1. Diet. Fats should be avoided; skimmed milk and lean meat are suitable. 2. Phosphate of soda, alkalies and alkaline waters, which seem to lessen the tenacity of the mucus, and also to allay the gastro- duodenitis. 3. Pilocarpine, to relieve itching. Gall Stones. Definition.—Calculi found in the gall bladder, or rarely in the biliary ducts in the liver, composed chiefly of cholesterine. Causes.—1. Age and sex. Most common in women between twenty-five and forty. 2. Sedentary habits seem to predispose to their formation. Morbid Anatomy.—1. Characteristics of the calculi. Usually multiple in number ; the size varies from sand to the size of a hen's egg; they usually show facets from pressure against each other; they are brown in color, and composed chiefly of cholesterine with some pigment 2. Condition of the gall bladder. As a rule, the gall bladder is in a state of chronic inflammation. 3. There may be fistulcs between the gall bladder and the stom- ach or bowels. practice of medicine. 157 Symptoms.—None, unless a stone lodges in the common bile duct; then gall stone colic occurs, characterized by violent pain under the ribs on the right side; the pain radiates to the back, is very intense, and often causes extreme prostration. It is usually followed by jaundice. Diagnosis.—Gall stone colic is distinguished from simple colic by the absence of flatulence and the seat of the pain; from renal colic by the seat of the pain and the presence (sometimes) of blood in the urine in the latter disease. Prognosis.—The prognosis is generally good, but a stone may lodge in the gall duct and cause dropsy of the gall bladder, or may even cause obstruction of the bowels. Treatment—1. To relieve pain and relax spasm by opiates, chloroform, hot baths, phenacetine, &c. 2. To prevent the formation of gall stones by choleate ot soda, alkalies, and alkaline waters. 3. To remove the stone by cholecystotomy, or the gall bladder by cholecystectomy. Dropsy of the Gall Bladder. Causes.— 1. Catarrh of the gall duct, causing swelling and ob- struction. 2. Gall stories stopping up the canal. 3. Outside pressure on the gall duct, from cancer, &c. Morbid Anatomy.—1. The size of the gall bladder is greatly increased. 2. The wall is thickened. 3. The contents are at first bile, but afterwards the bile is ab- sorbed and a mucous secretion takes its place. Symptom.—None characteristic. Physical Signs.—On palpation and percussion, a pear-shaped, fluctuating tumor underneath the ribs on the right side. Diagnosis.—1. From abscess, by the seat and size of the en- largement and the fluid drawn by the aspirator. 2. From cancer, by the absence of pain and cachexia. Prognosis.—Serious, because of the difficulty usually in re- moving the cause. Treatment. —1. To relieve the catarrh of the bile ducts, 2. To remove the gall stones. 3. To empty the gall bladder by aspiration, i58 practice of medicine. Diseases of the Pancreas. Acute Pancreatitis. Frequency.—The disease is probably very rare. Causes. — Gastro-duodenitis has been the cause usually in those cases which have been carefully studied. Morbid Anatomy.—It may occur in one of three forms— (1) suppurative ; (2) hemorrhagic; (3) gangfenous. Symptoms.—The symptoms come on suddenly, and are those of peritonitis limited to the pancreatic region. Prognosis.—The prognosis is grave in all cases. Treatment—is limited to sustaining strength and relieving pain. At a later stage there is a possibility that good may be ac- complished by surgical interference. Nothing definite is known with respect to chronic pancreatitis. Pancreatic cysts, due to the obstruction of the pancreatic duct, have been frequently observed, and have occasionally been cured by surgical means. Diseases of the Spleen. Affections of the spleen are nearly always secondary, and are of little practical importance, except in the diagnosis of the acute infectious diseases. Congestion of the spleen occurs in all affections leading to passive hyperemia of the abdominal viscera, such as cirrhosis of the liver and certain cardiac diseases. It occurs also in the acute infectious diseases, probably as a re- sult of the circulation of leucomaines through it. Splenitis is rare: it may lead to an increase in the connective tissue of the organ or to abscess formation in cases of septic in- farction. Waxy degeneration of the spleen sometimes occurs, but is in itself of no practical significance. Enlargement of the spleen, which is often permanent, is especially common after malarial affections. It gives rise to no special symp- toms, but is readily detected on palpation and percussion. The anti-malarial remedies will frequently cause the disappear- ance of the splenic enlargement. practice of medicine. 159 CHAPTER V. DISEASES OF THE HEART. Pericarditis. Definition and Frequency.—Inflammation of the pericardium. It is quite frequent. Causes.—It is rarely primary. 1. Acute rheumatism is the most common cause. The pericar- ditis is probably due to the morbid matter circulating in the blood and lymph. 2. The acute infectious diseases, especially septicaemia and the exanthemata, cause it through the action of leucomaines. 3. Brights disease (nephritis) probably acts in consequence of the retention of irritating waste products. 4. Tuberculosis is a common cause. 5. Injuries may cause it, but rarely do so. Morbid Anatomy. — 1. The changes in the pericardium consist in cloudiness of the endothelial cells, and later, roughness from fibri- nous exudate ; redness is, of course, present. 2. The muscular tissue of the heart is more or less infiltrated with serum and cells, and its fibres undergo cloudy swelling, and possibly fatty degeneration later on ; or connective tissue may form in spots. 3. The exudate may be serous, sero-fibrinous, fibrinous, puru- lent or hemorrhagic ; usually it is fibrinous at first, and serum is subsequently added. 4. Results. The pericardium may be shaggy from the rubbing together of the fibrinous exudate on the opposing surfaces of the membrane; or there may be adhesions more or less extensive be- tween the costal and cardiac pericardium; or there may be calcifi- cation of the exudate (so-called ossification of the heart). Absorption is possible, but very rare. Symptoms.—The symptoms are often latent or overshadowed by the causative disease. 1. Cardiac. Pain and constriction in the praecordial region from the pressure of the exudate on the nerve filaments of the pericar- dium and palpitation from the efforts of the heart muscle to neu- tralize the effects of pressure of the effusion. The pulse is quick, jerky, and when there is much effusion weak, because the pressure of the effusion on the heart interferes with the filling of its cavities, and hence only a small quantity of blood is thrown into the vessels by each systole. 2. Respiratory. Dyspnoea is present when there is much effu- sion, because very little blood is forced into the lungs to be oxy- genated. i6o practice of medicine. 3. The temperature varies ; it is usually elevated somewhat— 1010 to 1030—but in septic and some rheumatic cases may be higher. Physical Signs.—1. On inspection, there may be cyanosis, from want of oxygenation of blood ; the praecordial region may be dis- tended with effusion. 2. On palpation, the heart's impulse is often feeble, from the serous fluid surrounding the organ. The rubbing together of the pericardial surfaces may be felt. 3. On percussion, the area of cardiac dullness may be greatly in- creased by the serous exudate. 4. On auscultation, friction sounds may be heard, which are due to the rubbing of the roughened pericardial surfaces against each other; but these friction sounds maybe prevented by (1) serous effusion, (2) adhesions. Diagnosis.—1. From endocarditis it is distinguished by the more superficial character and greater roughness of the sounds. Pericardial sounds do not extend far. 2. From pleurisy by the seat of the sounds and the fact that they continue while the patient holds his breath. 3. From hypertrophy by the fact that the apex beat in pleural effusion is not at the limit of the dullness ; the history of the case also is different. Prognosis.—The prognosis is usually favorable as to life, ex- cept in (1) septicaemia, (2) nephritis. The duration is from one to three weeks. Results.—More or less adhesion of the pericardial surfaces al- ways occurs. Dilatation of the heart may occur from softening of the cardiac walls and intra-cardiac pressure. Treatment.— 1. To check inflammation by (1) absolute quiet; (2) aconite; (3) veratrum, and in the late stages by blisters; digi- talis, if the heart's action is feeble. 2. To relieve the causative diseases (q. v.) 3. To relieve pain, by opiates, which should be given cautiously, and by counter-irritants or hot applications. 4. To sustain strength, by suitable diet; stimulants to be avoid- ed, if possible. 5. To promote absorption by iodides, iron, stimulants, blisters, &c. 6. To remove serous or purulent exudate by— (1) aspiration, in cases of serous exudate which is so large as to endanger life; (2) free incision and drainage (very rarely) if the exudate is purulent. $ k PRACTICE OF MEDICINE. 161 HYDRO-PERICARDIUM. H.EMO-PERICARDIUM. PNEUMO-PERICARDIUM. Hydro-pericardium is due to passive hyperaemia, &c. and should receive the same treatment as the other forms of dropsy. Hcemo-pericardium is a collection of blood in the pericardial cavity; it may be due to the breaking of adhesions or to hemor- rhagic disease, or to inflammation. The treatment is chiefly pal- liative. Pneumo-pericardium is the presence of air or gas in the peri- cardium. It may occur from injury or ulceration. Endo-carditis. Definition and Frequency.—Inflammation of the lining mem- brane, of frequent occurrence. Varieties.—i. Acute exudative; 2, ulcerative. Causes.—Rarely idiopathic or primary. 1. The same as those of pericarditis (q. v.). 2. Chona; it is not known why it causes endo-carditis. Morbid Anatomy.—A. Exudative. 1. Seat. The left side of the heart is nearly always involved because of strain on it; it occurs in patches, and the valves are most commonly affected. 2. Structural changes. Papillary excrescences, composed of leu- cocytes, form usually on the edges of the valves; the endothelial cells over these undergo cloudy swelling and degeneration, and fibrin is deposited on the excresences. The edges of the valves may adhere to each other, causing narrowing of the valvular opening (obstruction), or the valves may be crumpled from contraction of new connective tissue, or the chordae tendinae may be shortened for the same reason; both conditions cause insufficiency of the valves. B. Ulceration.— 1. Seat. Usually on valves of left side. 2. Micrococci are present and lead to 3. Ulcerative, which may cause a piece of the valve to be broken off, or may cause 4. Valvular aneurism, from pressure of the blood on the valve, thinned by the ulceration. 5. Pyaemic abscess in other organs are common from septic emboli. Symptoms.—The subjective symptoms are usually very ill- defined. 1. The pulse is quick and jerky, but not full, because the heart is more irritable than normal, and so contracts before its cavities become fully distended with blood. In the ulcerative form it is rapid and feeble. 2. The temperature is elevated, probably from the absorption of 21 l62 PRACTICE OF MEDICINE. leucomaines, in the exudative cases; in these cases it is rarely over 1030. In the ulcerative form, the temperature often reaches 1060, and may be preceded by a chill and followed by sweating , it is due to absorption of septic matter. 3. The respiration is quickened in consequence of the increased rapidity of circulation and the elevated temperature (see Fever). 4. Typhoid symptoms are common in the ulcerative form, and also dyspnoea and cyanosis; these latter are probably due to the lodgment of septic emboli in the pulmonary vessels. Physical Signs.—1. On inspection and palpation the cardiac impulse is marked, from irritability of the heart. 2. On percussion, no information of importance can be obtained, 3. On auscultation, in fresh cases and first attacks, a soft, blow- ing sound is heard, commonly at the apex, from the passage of the blood over the excresences in the valves, or from the formation of " whirls" in the blood by obstruction or regurgitation. Diagnosis. — 1. From pericarditis by softness and greater dis- tance of the sound. 2. From functional cardiac murmurs by the history of the case (usually rheumatic), and by the situation of the murmurs, functional being at the base and those of endo-carditis usually at the apex. Prognosis.—The prognosis, as to life, usually good in the ex- udative form; almost hopeless in the ulcerative. The exudative form usually leaves crippled valves. Results.—1. Calcareous degeneration of vegetations (excres- ences) on the valves. 2. Embolism, which is simple in exudative form and septic, lead- ing to pyaemia, in ulcerative. 3. Valvular disease. (1) Adhesions of the edges; (2) crump- ling ; (3) calcareous degeneration, in 25 per cent, of the cases. Obstruction at a valve may be caused by thickening or adhe sions. Insufficiency may be caused by (1) crumpling of valves; (2) con- traction of chordae tendinae. Treatment.—1. To relieve the causative condition, care being taken not to cause prostration by excessive use of salicylates. 2. To allay irritability of the heart by absolute quiet, aconite or veratrum, if pulse is strong, digitalis, if pulse is weak. 3. To relieve pain by counter-irritants, hot applications and mor- phia, if absolutely necessary (pain is rarely severe). 4. To sustain strength by nutritious food and stimulants. In the exudative form stimulants should be used guardedly; in the ulcer- ative form, freely. PRACTICE OF MEDICINE. 163 Valvular Diseases of the Heart. Causes of Cardiac Murmurs : 1. Obstruction to the flow of blood at the cardiac orifices. 2. Regurgitation of blood at the cardiac orifices. 3. Change in the quality of the blood. 4. Spasmodic contraction of the chordae tendinae. Time and Nature, Seat, and Area of Diffusion of Valvular Murmurs:— Valve. Nature of Af-fection . Time of Oc* currence. Seat of Greatest Dis-tinctness. Area of Diffusion. 1. Mitral. 2. " 3. Aortic. 4. " 5. Tricuspid. 6. " Obstruction. Regurgitation. Obstruction. Regurgitation. Obstruction. Regurgitation. Presystolic. Systolic. Systolic. Diastolic. Presystolic. Systolic. Apex. Apex. Second right inter-costal space. Ensiform cartilage. Towards the left. Towards the left and behind at lower angle of scapula. Along the large arteries. Over the sternum. Unknown, disease very rare. Slight; not heard to the left or above third rib. Pulmonary valvular sounds are extremely rare, except accentua- tion of the second sound from obstruction to the flow of blood in the lungs; the sounds are heard most distinctly at the second left intercostal space, close to the sternum. Exocordial murmurs are (1) pericardial; (2) cardio-respiratory; the latter occur at the apex, are systolic in time and due to the forcing of air out of a bronchus or air cells by the cardiac pulsation. Causes of Valvular Diseases:—1. Endo-carditis is by far the most common cause of valvular disease (see "Results" of Endo- carditis. 2. Age. Disease of pulmonary valves usually congenital, be- cause right side ot the heart does more work than the left in foe- tal life. Mitral disease most common in the young, because rheumatism is more common in early life. Aortic disease is common in later life, because it may arise from extension of atheroma from the aorta to the aortic valves. 3. Occupation. Laborious occupation may cause aortic disease from increased tension in the vessels and consequent strain on the aortic valves. 4. Obstruction to the flow of blood in the systemic arteries may cause overfilling of left ventricle and consequent regurgitation of the mitral valve. 5. Emphysema and other obstructions to the flow of blood in the lungs lead to distension of the right ventricle and tricuspid re- gurgitation. 164 PRACTICE OF MEDICINE. Morbid Anatomy. — 1. The sice of the heart is increased in nearly all valvular affections from compensatory hypertrophy. 2. The valves (see "Results" of Endo-carditis) may (1) be crum- pred; (2) be adherent at their edges; (3) have calcareous nodules on them ; (4) be torn so as to have a strip hanging loose in the cavity; (5) be prevented from closing by contraction of chordae tendinae. 3. Changes in other organs occur when compensation fails and consist in passive hyperaemia of the lungs, liver, kidneys, bowels, spleen, &c. Aortic Obstruction, or Stenosis. (Narrmuing of the Aortic Opening) Symptoms.—The symptoms are not well-marked, indeed, are scarcely noticeable when compensation is good. The pulse is small and slow, because the narrow aortic opening prevents the ventricle from throwing much blood into the arteries and it enters slowly. Results.—1. Hypertrophy of the / (5) the vena cava. 4. Recovery is possible from coagulation of blood in the sack and gradual closure of the cavity in this way. Treatment.—The treatment which has given the best results consists in absolute quiet in the recumbent posture; a very small allowance of food, and the administration of iodide of potassium. Surgical treatment has not given good results, nor has the elec- trical treatment—the insertion of a needle connected v/ith a gal- vanic battery into the sack to produce coagulation. 23 i78 PRACTICE OF MEDICINE. CHAPTER VI. DISEASES OF THE KIDNEYS. Albuminuria. (Albumin in the urine.) Divisions and Causes of Albuminuria. —i. False, in which the albuminuria is due to (i) suppuration somewhere in the urinary tract, as oecurs in cystitis and gonorrhoea, or (2) hemorrhage, in which the albumin is poured into the urine along with the other constituents of the blood. 2. True albuminuria, which may probably be caused by one of the following conditions— (1) Alterations in blood pressure which probably explains those cases of albuminuria occurring after violent exercise or at certain hours of the day (cyclical albuminuria) ; (2) Changes in the vascular walls, as in waxy degeneration of the kidneys ; (3) Changes in the composition of the blood which may act in two ways—first by making the blood itself more apt to pass through a membrane, and secondly, by rendering the membrane more permeable to the albumin by defective nutrition of the epithelial cells; (4) Degeneration of renal epithelium, which is by far the most important cause, and occurs in inflammatory affections and prob- ably also in connection with waxy degeneration. Tests for Albumen.— 1. Heat causes coagulation to a greater or less extent provided the urine is acid. 2. Nitric acid added to the urine precipitates the albumen. Heat causes precipitation of earthy phosphates also, but these are at once dissolved on the addition of an acid; if there is a pre cipitate with both nitric acid and heat, albumen is certainly present in the urine. Significance of Albuminuria.—The occasional occurrence of albumen in small quantity in the urine after violent exercise or a meal rich in albuminous food is entirely consistent with health. If it is present persistently and in considerable quantity it is always a serious symptom, because it shows that the ephithelial cells are in- capable of doing their work (renal inadequacy) and that urinary solids are retained in the blood. It should be distinctly understood, however, that the absence of albumin from the urine is not an evidence that the kidneys are sound. PRACTICE OF MEDICINE. iyg Quantitative Test for Urinary Solids.—The amount of uri- nary solids passed in twenty-four hours may be determined with reasonable accuracy in a very simple way. Multiply the last two figu es of the specific gravity of the urine by the number of ounces passed in twenty-four hours; the result will be the amount of urinary solids expressed in grains. Normal sp. gr. = 1020; normal amount of urine passed in twenty-four hours about 48 oz.; amount of solids, 960 grains. Tube Casts. Varieties.—1. Hyaline, which are composed of albuminoid substance which has coagulated in the urinary tubules and appear in the urine as glassy or homogeneous cylinders from 2TW t° -^ of an inch in diameter. In some cases probably the casts consist of an inflammatory exudate, but the nature of the material in many cases is unknown. 2. Epithelial, which are merely hyaline casts on the surface or in the substance of which are epithelial cells from the urinary tubules. 3. Blood casts are sometimes merely coagula of blood formed in urinary tubules in cases of hemorrhage, and at other times a hem- orrhagic exudate occurs in inflammation of the kindneys and leads to the formation of blood casts. 4. Fatty casts contain epithelial cells which are undergoing fatty degeneration, or fatty particles formed by the breaking up of such cells. 5. Granular are formed by the breaking up of epithelial cells without fatty degeneration. Significance of Casts.—Several kinds ot casts are usually found in the same specimen of urine. Hyaline casts, especially when of small size, are usually least serious in significance. Epithelial and blood casts usually appear in recent cases of considerable severity. Fatty and granular casts usually appear in chronic cases. l8o PRACTICE OF MEDICINE. Acute Uraemia. Uraemic poisoning. Varieties.— I. Eclampsia or convulsive form. 2. Comatose form. The comatose is the most common except in puerperal cases. Causes.—The essential cause is the retention in the blood of morbid matters which should be removed by the kidneys (loss of efficiency of renal epithelium). It may occur in the various forms of nephritis (or Bright's dis- ease q. v.), in waxy degeneration of the kidneys, often classed with Bright's disease, in cancer and tubercle. Symptoms.—A. Premonitory, i. Nervous. Headache, dull- ness, disturbances of vision, from retention of morbid matters in the blood. 2. Digestive. Nausea and vomiting, and sometimes diarrhoea, from the action of urinary solids on the nerve centres and also on the intestinal mucous membrane. 3. Respiratory. Attacks of dyspnoea (renal asthma) probably from the action of the impure blood on the respiratory centres. 4. Urinary. The amount of urine is usually greatly diminished, probably because the exudate around the glomeruli compresses the vessels and interferes with the discharge of water or the solids in solution therein. The sp. gr. is usually high, about 1030, because the amount of water is both actually and relatively increased. The total amount of solid urine is always greatly diminished. Albuminuria and tube casts are always present. B. During the attack. 1. In the convulsive form there is loss of consciousness, clonic convulsions, interrupted breathing, irregu- larity of the pulse, lividity of the skin and foaming at the mouth. A convulsive attack usually lasts a few moments only, but they usually recur at intervals of a few hours, and there is unconscious- ness during the intervals. 2. In the comatose form there is profound unconsciousness, stertorous breathing, a full and slow pulse and usually contraction of the pupils. Diagnosis.—It is distinguished from, 1, Epilepsy, by the his- tory of the case and the urinary symptoms. 2. Apoplexy. 3, Hys- teria. And 4, Opium poisoning by the presence of albumin and casts in the urine. Prognosis.—The prognosis is always serious, but in cases of acute Bright's, especially the puerperal form, recovery generally occurs. PRACTICE of medicine. 181 Treatment.—A. Prophylactic, i. The diet should be poor in nitrogenous food except milk, which may be given freely; it washes out the kidneys. 2. Diuretics are not advisable, except tzvo, water or lithia water and digitalis; these directly increase the flow of water from the kid- neys but do not stimulate the cells. 3. To remove zvaste matters by the skin and bozvels. To induce sweating, the hot pack, steaming and pilocarpine may be employed. To cause zvatery actions from the bowels, calomel, jalap, elaterium and the saline cathartics are used. B. During the paroxysm, if of convulsive form— Chloroform by inhalation, chloral by enema, the bromides in the same way, and morphia hypodermically, give the best results. Antipyrine, amyl nitrite and other agents to allay nervous irrita- bility or to relax spasm, have been employed. Circulatory Changes Which are Common in Renal Diseases. Changes in the Blood Vessels.—In all or nearly all cases of Bright's disease there is more or less thickening of the zvalls of the smaller blood vessels due probably to inflammation set up by the circulation in the blood of some irritating substance or substances. This change is frequently called fibroid degeneration of the vessels or arterio-capillary fibrosis. The "fibroid" or connective tissue is formed from the leucocytes which pass out of the vessels in inflammation. Changes in the Heart.—Hypertrophy of the heart occurs from the increased work put upon the heart in consequence of the changes in the blood vessels and the high arterial tension caused thereby. Dilatation occurs later on, just as in other cases of cardiac hy- pertrophy. Character of the Pulse.—As a rule, the pulse, in diseases of the kidneys, is slow, full and strong—the pulse of increased arterial tension; the cause of this is evident from th2 changes in the heart and vessels. When dilatation of the heart occurs, however, from failure of compensation, the pulse becomes quick and feeble. Influence of Circulatory Changes on the amount of urine discharged.—As a rule, the greater the blood pressure, the greater the amount of urine discharged, unless there is counter-pressure on the 182 PRACTICE OF MEDIClNFt. vessels of the glomeruli by an inflammatory exudate. It follows, therefore, and is in accordance with clinical experience, that in parenchymatous nephritis when there is much exudate the amount of urine is diminished in spite of the increased arterial tension ; while in interstitial nephritis, when the connective tissue framework is chiefly involved, the amount of urine is increased. This difference in the pathological condition in parenchymatous and interstitial nephritis explains also the fact that dropsy is a com- mon symptom in parenchymatous disease and is rare or slight in the interstitial form. Waxy degeneration comes between paren- chymatous nephritis and interstitial nephritis with respect to the amount of urine discharged and the degree of dropsy ; if the glom- erular vessels are chiefly involved it approaches parenchymatous nephritis in symptoms, while if other vessels are chiefly involved the dropsy is less marked and the urine more abundant. It must be remembered also that in waxy degeneration there is generally great muscular weakness from the accompanying conditions and the vascular tension may be diminished in consequence. Renal Hyperemia. Varieties.— i. Active. 2. Passive. Active hyperaemia is usually the first stage of an inflammatory process and is practically indistinguishable from nephritis, except by its short duration. The probable causes are exposure to cold and the use of renal irritants, such as turpentine and cantharides. The symptoms are pain in the back, headache and scanty and dark-colored urine, which contains albumin and often blood or hy- aline casts. The diagnosis is based on the rapid improvement under appro- priate treatment. The prognosis is usually favorable, but the fact should be borne in mind that this affection is often the commencement of ne- phritis. The treatment consists in dilating the vessels of the skin by warm baths, pilocarpine, amyl nitrite or nitro-glycerine, and in washing out the kidneys by administering large quantities of pure water or of lithia water. Passive Hyper/emia. Causes.—Venous stasis (passive hyperaemia) from heart dis- ease, certain pulmonary affections, as emphysema, and pressure on the veins by the gravid uterus, dropsical effusion or tumors. PRACTICE OF MEDICINE. 183 Morbid Anatomy.—1. The size of the kidneys is increased from the amount of blood and the exudate or transudate which occurs. 2. The color is dark and the consistence firmer than normal, in old cases especially, because— 3. There is an increase of connective tissue which is formed from the leucocytes which have traversed the vessels (see Results of passive hyperaemia). 4. Cloudy szvelling, or albuminoid degeneration of the renal epithelium, also occurs from a deficient supply of arterial blood. Symptoms.—The pulmonary', digestive and nervous symptoms are those of venous stasis from any cause. The urinary symptoms are scantiness from diminished arte- rial tension, dark color from the presence of blood or of blood- coloring matter and high specific gravity because the water is di- minished more than the salts. Albumen and casts are usually present. Diagnosis.—The diagnosis is based on the causative condition. Prognosis.—The prognosis is usually unfavorable because it occurs usually as a result of incurable heart or lung trouble. Treatment.—The chief aim is to relieve the passive hyperoemia and increase the arterial tension. Digitalis is by far the best remedy for this purpose. Bright's Disease. A number of different affections of the kidneys resembling each other, however, in certain particulars, have been included under the general name of Bright's Disease. Classification.—The following classification is sufficient for practical purposes— 1. Parenchymatous inflammation of the kidneys in which the cells of the renal tubules are chiefly involved. It may be either (1) acute or (2) chronic. 2. Interstitial inflammation of the kidneys, in which the part chiefly affected is the connective tissue framework of the organs. It is alzvays chronic in course. 3. Lardaceous or amyloid or zvaxy degeneration of the kidneys ; in this form the walls of the smaller blood vessels are primarily and chiefly involved; the affection is degenerative and not inflammatory in character, and runs a chronic course. 184 PRACTICE OF MEDICINE. Acute Bright's Disease. (Acute nephritis ; acute desquamative nephritis ; acute parenchy- matous nephritis.) Definition and Frequency.—An acute inflammation of the kidneys, in which the parenchyma is chiefly involved, and which is of common occurrence. Causes.__I. Sudden chilling of the body; the mode of action of this cause is* unknown ; it is probably connected with the in- creased work thrown upon the kidneys when the vessels of the skin are contracted. ...... 7. it . a -> The acute (rarely the chronic) infectious diseases ; the inflam- mation is probably due to the action of the leucomaines on the kid- nevs by which they are in part eliminated. The disease is especially common after scarlet fever, but may also occur as a sequel of diph- theria, typhoid fever, cerebro-spinal meningitis and the other acute infectious diseases. 3. Certain irritants, such as turpentine and canthandes, which are eliminated by the kidneys. 4 Pregnancy is an occasional cause; excessive work and the elimination of irritants is the probable explanation in these cases. Morbid Anatomy.—1. The size of the kidneys is more or less increased, from infiltration with the exudate. 2. The color is grayish because the pressure of the exudate forces the blood out of the vessels; but often red spots are seen from the congestion of the glomeruli or a bloody exudate into Bowman's capsule. 3. This capsule is often filled with an exudate which compresses the vessels in the glomeruli. 4. The epithelium of the convoluted tubules is cloudy or may be peeling off, and the tube itself is often filled with the exudate and desquamated cells. Symptoms.— 1. Cutaneous. Dropsy is usually the most prom- inent symptom ; it is most marked abont the face (See Dropsy in General Pathology) and is in large amount because the plugging of Bowman's capsule and the convoluted tubules interferes with the discharge of water by the kidneys. The skin is usually pale from the action of the retained water on the red corpuscles. 2. Urinary. The amount of urine is diminished from the pres- sure of the exudate on the vessels of the glomeruli; the sp. gr. is high—often 1030, because there is relatively a greater diminution of water than of solids ; it contains albumen and casts, usually epi- thelial, hyaline and bloody, and the amount of urinary solids is di- minished. 3 The nervous symptoms are those premonitory of uraemia (q.v.). PRACTICE OF MEDICINE. I85 4. The ocular symptoms are rarely marked in acute Bright's, but there may be more or less disturbance of vision from the action of retained matters on the nervous system ; retinitis is rare in acute cases. 5. The digestive and respiratory symptoms are like those of threatened uraemia, and are due to the action of morbid matters on the nerve centres and the intestines, and also to the dropsical accu- mulation which interferes with breathing. 6. The temperature is rarely elevated above 1020 and often is not over ioo°. Diagnosis.—The diagnosis is based on the headache, nausea and respiratory disturbances, but above all on the urinary symptoms and signs. Scanty discharge, albuminuria and the presence of casts. Prognosis.—The prognosis depends on the age of the patient, the cause of the nephritis and the complications; it is better in chil- dren, and especially after scarlet fever, than under other circum- stances. Cases occurring in connection with pregnancy also have, as a rule, a favorable prognosis. Complications.—The most common complications are pneumo- nia, pleurisy, pericarditis and endocarditis. Causes of Death. — 1. Uraemia (or urinaemic poisoning) from the retention of morbid matters in the blood. 2. Pneumonia. It is not clear how this disease results from acute Bright's. 3. Dropsy, such as hydrothorax and pulmonary oedema. Treatment.—1. Dietetic. To diminish the work of the kidneys by giving nitrogenous food, except milk, in small quantities, and by increasing the action of the skin and bowels. 2. To remove the urinmnic solids and relieve dropsy by (1) such diuretics as digitalis and water or lithia water; (2) hydragogue cathartics; (3) diaphoretics. 3. To draw blood to the skin and so lessen the amount in the kidneys by poultices, baths and warm clothing. 4. To relieve symptoms as they arise. Chronic Parenchymatous Nephritis. (Chronic Bright's Disease.) Definition and Frequency.—Chronic inflammation of the kid- neys in which the parenchyma is chiefly involved. It is compara- tively common. / 24 186 PRACTICE OF MEDICINE. Causes.—I. Age and sex. Men in middle life are most liable to this affection. 2. Exposure to cold and dampness seems to be a cause, and acts probably by increasing the work of the kidneys, but the exact con- nection between cold and nephritis is not plain. 3. Alcohol is undoubtedly a cause; it probably acts as a direct irritant to the renal cells. In many cases no cause can be discovered. Morbid Anatomy.—Tzvo forms are described— I. The large white kidney. 2. The fatty and contracted kidney. They are different stages of the same disease. 1. The size is increased because of the exudate into the organ. 2. The color is zohiter than normal because the blood is pressed out of the vessels by the exudate. 3. The consistence is firmer because the urinary tubules are more or less filled with a solid exudate. 4. The capsule is more or less adherent; the longer the disease has lasted the greater the adhesion. 5. On microscopic examination the capsules of Bowman are found more or less filled with exudate ; and the vessels and glomeruli are surrounded in many places by connective tissue. The renal cells lining the tubules are either albuminoid and des- quamating at a comparatively early stage, or are fatty later on. The fatty and contracted form is merely a later stage of the large zvhite form, and the later the stage the more marked is the fatty de- generation and the greater the amount of connective tissue. The kidnevs are not uniformly affected, but the degenerative change is worse in some places than in others. Symptoms.—1. Cutaneous. Dropsy is present to a greater or less degree; it is due to the counter-pressure of the exudate on the glomeruli which prevents the flow of water from the vessels. In very chronic cases the dropsy is slight because the exudate is small in amount and the blood pressure is greatly increased by the cardiac hypertrophy. Pallor is usually a marked symptom, because of the hydraemic condition of the blood. 2. Urinary. Albuminuria is always present; the amount de- pends upon the activity of the inflammation. The quantity of urine is diminished in the earlier stages, but when cardiac hypertrophy occurs and the exudate diminishes it is increased. The amount of urinary solids is always less than normal because of the loss of renal epithelium. Casts—granular and fatty, chiefly—are always present. 3. The nervous and digestive symptoms are not usually marked unless an acute attack supervenes. PRACTICE OF MEDICINE. 187 4. Circulatory. The heart is hypertrophied and the pulse is full and strong (see Circulatory Changes in Renal Disease). 5. The special tense symptoms. Disturbances of vision are of fre- quent occurrence and are ccmmon'y due to an exudate into or an atrophy of the retina which is plainly visible as a white patch on ophthalmoscopic examination. Diagnosis.—The diagnosis is based on the urinary symptoms and signs and the dropsy. Prognosis and Duration.—The prognosis is unfavorable, but the disease may run on in a very chronic state for months or years. Complications.— 1. Pulmonary. Pneumonia and pleurisy are frequent complications. They are due to the irritation of waste products retained in the blood. 2. Inflammation of serous membranes generally; endocarditis, pericarditis and synovitis occasionally occur. 3. Cardiac hypertrophy is an invariable complication of cases of old standing. The way in which it is brought about has already been explained. Treatment.—The indications are— 1. To clear out the tubes by the administration of digitalis and the use of large quantities of water. 2. To lessen renal hyperaemia and the zvork of the kidneys by di- lating the vessels of the skin by warm baths, jaborandi and nitro- glycerine ; to administer only small quantities of nitrogenous food except milk, which may be given freely 3. To improve nutrition by cod liver oil (Loomis), iron and strychnine. 4. To relieve symptoms, such as dropsy, by diaphoretics, hydra- gogue cathartics, digitalis, small punctures and the aspirator. Headache and sleeplessness are best relieved by phenacetine and paraldehyde. Interstitial Nephritis. (Cirrhotic Bright's Disease.) Definition.—A very chronic affection of the kidneys in which the or^an becomes progressively smaller and harder than normal from atrophy of its parenchyma and in :rease of connective tissue. Causes.__Often no cause can be assigned ; the disease occurs in advanced life, and chiefly in men. Alcohol and lead, gout and rheumatism are supposed to be causes in some cases. All of these substances act as irritants to the renal cells during their elimination by that organ. 188 practice of medicine. Morbid Anatomy.— i. The size of the kidneys is very much less than normal. 2. The shape is irregular and nodulated from the contraction of the new formed connective tissue. 3. The consistence is much firmer than natural for the same rea- son, and the capsule is closely adherent. 4 On microscopical examination many of the glomeruli and urinary tubules are found atrophied and completely destroyed; those which remain are usually sound. There is an enormous in- crease in the connective tissue in the organs c Chanees in other organs. Arteno-capillary fibrosis and hy- pertrophy of the heart are always present and in many cases there is cirrhosis of the liver. Symptoms.—1. The onset is very gradual and insidious, and the symptoms are obscure. 2 Urinary The amount of urine is increased; the specific gravity is low; these changes are due to the hypertrophy of the heart and the absence of an exudate from the renal tubules. Albu- min may be present in small quantity, but is often absent because theglcmeiuli which remain are usi ally sound—ihose which are affected at all are entirely destroyed. The amount of urinary sol- ids is always diminished. 3 Cutaneous. Dropsy is never marked because there is no ex- udate in the tubules and the blood pressure is increased. Some dropsy in the ankles appears late from heart failure. 4. Headache and vertigo and sometimes local paralysis appear; the cause of these symptoms is not clear; probably they are con- nected with the retention of urinary solids. 5. Dyspeptic symptoms are also of common occurrence, and very distressing at times. Diagnosis.—The diagnosis from diabetes is made by the absence of sugar from the urine. • • u j A constructive diagnosis is often extremely difficult; it is based on (1) the increased flow of urine of low specific gravity; (2) the cardiac hypertrophy; (3) the nervous symptoms; and (4) the di- gestive disturbances. Prognosis— The prognosis is always bad ,\ the disease is pro- gressive ; the duration often months or years. Sudden uranua may occur from extension of disease to the remaining parenchyma- tous tissue, or death may result from complications. Complications — 1. Cardiac hypertrophy and arterio-capillary fibrosis have already been mentioned. 2. The pulmonary complications are similar to those of chronic parenchymatous nephritis with the addition of emphysema. 3. Cerebral hemorrhage occasionally occurs from disease of the vessels and hypertrophy of the heart. PRACTICE OF MEDICINE. I89 Treatment.—The treatment is chiefly symptomatic; the pre- vious disease (gout, rheumatism, &c.) should receive attention; alkaline waters should be administered; the blood pressure should be lowered by nitro-glycerine ; and headache, insomnia and other symptoms should be relieved as far as possible by phenacetine, sulphonal, &c. Waxy Degeneration of the Kidneys. (Lardaceous or amyloid degeneration.) Causes.— 1. Syphilis. 2. Suppuration. (See Amyloid Degen- eration in General Pathology). Morbid Anatomy.—1. The size of the kidneys is greater than normal. 2. The color is pale ; the consistence firm. 3. The seat of the degeneration is first on the vvalls of the blood vessels, but the renal cells and connective tissue may be involved later. 4. Microscopic appearances. The cells swell up and lose their outline; if tincture of iodine be applied they assume, a mahogany color. Symptoms.—The symptoms are very variable and not charac- teristic. I. Urinary. The amount of urine may be increased, but it is often diminished because of the general debility and lessening of blood pressure in consequence. The specific gravity varies with the amount passed. Albumin is sometimes present in large quantity when the glomeruli are involved, but is absent if the vasa recta only are diseased. The amount of urinary solids is but little lessened and there are fezv casts. 2. Dropsy is not usually very marked, because there is no exu- date into Bowman's capsules or the urinary tubules to prevent the discharge of fluid by the kidneys. 3. Nervous symptoms are not prominent because the amount of urinary solids is not much diminished. Diagnosis.—The diagnosis is based on the urinary symptoms and the occurrence of amyloid disease in other organs. Prognosis.—The prognosis is bad ; the duration long. Complications.—Waxy degeneration of the bowels, liver, etc Treatment.—That of the causative disease. i9o practice of medicine. Pyelitis. (Inflammation of the pelvis of the kidney.) Causes—1. Stone in the pelvis of the kidney. 2. Irritating drugs, such as carbolic acid, turpentine and can- tharides, which are eliminated by the kidneys. 3. Extension from the bladder in cases of cystitis. 4. Obstruction to the outflozv of urine leading to ammoniacal de- composition and consequent inflammation. Morbid Anatomy.—1. Redness and szvelliug of the mucous membrane. 2. An exudate which is mucc-purulent in character on the sur- face of the mucous membrane. 3. Sometimes hemorrhagic extravasations in the mucous mem- brane. Symptoms and Signs.— 1. Nervous. Pain in the region of the kidney and frequent desire to urinate are common symptoms, and are due to the hyper-irritability of the sensory nerves from the in- flammation. 2. Rigors and fever may occur from the absorption of leuco- maines. 3. The urine contains pus and "tailed" epithelial cells. Diagnosis—The diagnosis is based on the symptoms and the shape of the epithelium. Prognosis.—The prognosis depends on the cause; it is good if the cause can be removed. Treatment.— 1. The first indication is to remove the cause. 2. To dilute the urine by giving the patient large quantities of water or of lithia water. 3. To relieve the inflammation by copaiba, cubebs, chlorate of potash, eucalyptus, &c. Hydronephrosis. (A collection of fluid in the pelvis of the kidney.) Causes.— 1. Internal obstruction by a calculus. 2. External pressure on the ureter by a tumor, such as cancer pr possibly ovarian tumor. PRACTICE OF MEDICINE. I9T Morbid Anatomy—i. Changes in the kidney. The kidney be- comes greatly distended and atrophies. 2. The contents of the sack, which may be as large as one's head are at first urine simply, but later on the fluid contains a larger pro- portion of water. Symptoms. -The essential symptom is a tumor in the region of the kidney. Diagnosis.—It is diagnosed from an ovarian cyst by the different situation of the tumor. Prognosis—The prognosis is serious, but spontaneous recovery may ensue. Treatment—i. The emptying of the sack by (1) manipulation; (2) aspiration. 2. Surgical measures; removal of the sack if it is due to a stone. Hematuria. (Blood in the urine.) Causes.—Blood in the urine may come from— 1. The kidneys. 2. The bladder. 3. The urethra. Rarely from the ureter. Symptoms.—If the blood has come from the kidney it was prob- ably poured out in consequence of passive congestion, acute inflam- mation, or the presence of a calculus, and the urine will be smoky in color. If the blood has come from the bladder it is often in consider- able amount and forms a clot which may interfere with the dis- charge of urine. If the blood comes from the urethra it flows during the inter- vals between urinating. Diagnosis.—The diagnosis of blood is made by the microscope; the diagnosis of the cause and seat by the accompanying conditions. Prognosis.—The prognosis depends upon the cause; the hem- orrhage in itself is not serious. Treatment.—In cases of haematuria from the kidneys—ergot, gallic acid and tannic acid have been employed ; in paroxysmal malarial haematuria, quinine is indicated. Hemorrhage from the bladder and urethra belongs to surgery 192 practice of medicine1. Chyluria. ' (Chyle in the urine; fatty urine.) Causes.—This disease is confined for the most part to tropical countries and is due to the presence in the body—in the thoracic duct probably—of the filaria sanguinis hominis—a worm about three inches in length and very narrow. Symptoms.—The urine is white and milky in appearance and is rendered clear on the addition of ether, which dissolves the fat. The perspiration is sometimes cyhlous also. Diagnosis.—The diagnosis is made by examination with the microscope and by adding ether to the urine, which renders it clear. Prognosis.—The prognosis is serious, and death may be brought about by anaemia; but the duration is usually long. Complications.—Elephantiasis is a common complication and seems to be due to the same cause. Treatment.—Treatment seems to be of little avail. Picro-nitrate of potassium has been advised. Nocturnal Incontinence of Urine in Children. Causes.— 1. Acidity of the urine. 2. Irritability of the bladder. 3. An adherent prepuce, or thread worms in the bowel or vagina. 4. A weak state of the sphincter muscle. Treatment.—1. To lessen the acidity of the urine by giving bi- carbonate of potash. 2. To lessen the amount of urine formed by giving the child only a small quantity of fluid in the evenings. 3. To lessen the irritability of the bladder by belladonna and bro- mide of potassium. 4. To relieve an adherent prepuce or remove zvorms. 5. To strengthen the sphincter muscle by strychnine and cantha- rides. practice of medicine. 193 Morbid Conditions of the Urine and their Significance. Loss of Transparency may be due to the presence in the urine of 1, Mucus. 2. Urates. 3. Phosphates. 4. Pus. 5. Blood. 6. Bacteria. 1. Mucus in the urine, if in excessive quantity, shows some irri- tative or inflammatory condition of the bladder. 2. Urine containing an excess of urates is clear when passed, but the urates are deposited as a pinkish sediment on cooling. Their presence is of very little clinical significance, but calculi may be formed from them. 3. The presence of phosphates in excess shows some digestive disturbance and may lead to the formation of a phosphatic calculus. The condition leading to their excessive formation is best treated by the mineral acids and nux vomica. 4. Pus in the urine may be due to urethritis, cystitis, pyetitis, nephritis or to the bursting of an abscess into the urinary passages. 5. Bloody urine has already been considered. 6. Bacteria always develops in urine a few hours after it is passed, unless it is sterilized, and they may develop in the bladder before the urine is passed if an unclean catheter has been passed. The Color of the Urine depends upon (1) the quantity passed; (2) the coloring matter and other substances which it contains ; it is rendered dark by bile and smoky by blood. It is high colored in fever cases, but the color under these circumstances is of little sig- nificance. The Quantity of Urine passed depends in a general way upon (i) the amount of fluid taken into the body; (2) the blood pressure. It is nearly always greatly increased in cases of diabetes mellitus. The Specific Gravity is usually inversely in proportion to the quantity passed, except in cases of diabetes, when the amount is large and the sp. gr. high, from 1025 to 1040. Reaction of the Urine.—The urine may become alkaline from fermentation or it may be excessively acid from an excess of uric acid. Urinary Deposits.—The most common urinary deposits are (1) urates of soda and ammonia; (2) earthy phosphates; (3) oxa- late of lime, and (4) uric acid. The significance of the urates and phosphates has already been stated. Oxalate of lime appears in the urine as a result of imperfect metabolism or from the use of certain articles of food (sorrel). If the deposit persists it is liable to form a calculus. Uric acid is often found in the urine in excess; it is nearly re- lated to the [gouty diathesis, and is due to the inadequacy of the i94 PRACTICE of medicine. The following table for facilitating the examination of urinary deposits by chemical means and by the microscope is a modification of that of Bowman : ist. Chemical Examination— I. The sediment dissolves when warmed . Urates 2. Not soluble when warmed, but soluble in acetic acid........... . Earthy phosphates 3. Insoluble in acetic acid, but soluble in di- lute hydrochloric acid.......Oxalate of lime 4. Insoluble in dilute hydrochloric acid, but purple with nitric acid and ammonia . Uric acid 5. Soluble in ammonia the solution leaving on evaporation hexagonal crystals . . Cystine 6. Milky appearance rendered clear by ether..............Chylous urine 2nd. Microscopical Examination— 1. If the deposit is crystalline— (1) Lozenge-shaped, rhomboidal or stel- late crystals..........Uric acid (2) Three-sided prisms with beveled edges and truncated ends, or feathery, fern- like crystals ..........Triple phosphates (3) Octahedral (envelopej or dumb-bell crystals............Oxalate of lime (4) Rosette-like tables........Cystine (5) Needle-shaped crystals, grouped in bundles or globular masses . . . Tyrosine 2. If amorphous or rounded particles— (1) Soluble when warmed......Urates of soda (2) Soluble in acetic acid.......Phosphate of lime (3) Yellowish grains, often spicular . . . Urate of ammonia (4) Round globules, with dark edges . . Fat (5) Dark globules resembling fat ... . Leucine (6) White and milky.........Chyle 3. If organized particles— (1) Granular corpuscles in stringy ag- gregation ...........Muco-pus. (2) Detached granular corpuscles . . . Pus (3) Irregularly-shaped scales.....Epithelium The significance of these various deposits has already been stated. Tube casts were described in an earlier part of this chapter. PRACTICE OF MEDICINE. 195 CHAPTER VII. DISEASES OF THE ORGANS OF LOCOMOTION. Acute Articular Rheumatism. (Inflammatory Rheumatism.) Definition and Frequency.—An acute general disease charac- terized by inflammation of one or more of the larger joints and probably due to the presence of lactic acid in the blood. It is of very common occurrence. Causes.— 1. The essential cause is probably the presence of lactic acid in the blood ; probably this results from the action of a germ on albuminoid bodies. 2. The disease is most common in temperate climates and especi- ally after exposure to cold and dampness. 3. Age. It is most common between the ages of fifteen and forty, and— 4. Heredity seems to play a certain part in its production. 5. Impairment of the general health seems to be a predisposing cause. Morbid Anatomy.—1. The blood contains lactic acid and fibrin factors in excess (?). 2. The joints are swollen, the synovial membranes somewhat reddened and there is a serous effusion or exudate into the affected joints. Symptoms.—A. Premonitory. 1. Sore throat (tonsilitis) is a frequent precursor of rheumatic fever. 2. Some digestive disturbances, such as cholera morbus, may also occur. B Symptoms of the developed attack. 1. The joints. One or more of the large joints are involved and frequently the disease may suddenly disappear from one joint and appear in another. They are swollen, excessively tender and pain- ful on movement and usually somewhat red. 2. The temperature is elevated usually from 1030 to 1050, but it may reach 1 io°. 3. Circulatory. The pulse is quick and often jerky, probably from the effect of the lactic acid in the blood on the heart. 4. Cutaneous. Acid sweats occur in almost all cases and at fre- quent intervals. 196 PRACTICE OF MEDICINE. 5. The urine is apt to be excessively acid and rarely it contains albumin. 6. Digestive. Acid dyspepsia is a frequent concomitant; consti- pation is usually present. 7. Nervous. Besides the pain in the joints there may be head- ache and occasionally violent delirium. Complications.—1. Cardiac. Endocarditis occurs in about one-third of the cases and pericarditis nearly as often. They are doubtless due to the morbid matters in the blood. 2. Nervous. Delirium has already been mentioned, but it is sometimes so prominent as to be a serious complication (cerebral rheumatism.) Sequelae.—1. Valvular disease of the heart is the most common and by far the most serious sequel. 2. Chorea occurs as a sequel in many cases. 3. Chronic inflammation of the joints rarely results. Diagnosis.—I. From pyaemia it is distinguished by the history of the case and the more severe constitutional disturbance in pyaemia. 2. From simple synovitis by the fact that in synovitis but one joint is usually involved and there is no acid sweat. Prognosis.—The disease is rarely fatal, the mortality being only about 3 per cent.; it is dangerous from the results (valvular disease). Duration.—The usual duration is from three to six weeks, but mild cases may terminate in a day or two. Treatment.—A. Hygienic. The room should be large and airy; the clothing should be warm (flannel); the diet should be light and unstimulating. B. Medicinal. The indications are— 1. To relieve pain and shorten the disesase. 2. To prevent cardiac complications. 1. To relieve pain salicylic, acid or salicylate of soda is by far the best drug. It rarely shortens the course of the disease and it does not prevent cardiac complications. Salol has a very similar effect. Phenacetine is less useful. Oil of zvintergreen has the same effect as salicylic acid. Morphia or codeia may be given, but are rarely necessary. Locally ice bags, poultices, chloroform and aconite and blisters have been used to relieve pain; they are of doubtful value. The limb may be enveloped in cotton batting with advantage. 2. To prevent cardiac complications the alkalies, such as bi-car- bonate of potassium, are of undoubted value. Relapses are common, and rest in bed with persistent use of sa- licylate of soda is advisable for a time after apparent recovery. PRACTICE OF MEDICINE. 197 Chronic Articular Rheumatism. Causes.—This disease is far more common in elderly people than in young ones; it seems to be hereditary and exposure to cold and dampness is an exciting cause; razv zveather will bring on an attack in persons liable to it. Morbid Anatomy.—The joints are somewhat swollen and the synovial sack and sheathes of the tendons are thickened. Symptoms.—The joints are more or less stiff and painful; the pain being usually dull and aching in character. The knees, ankles and wrists are usually involved. Diagnosis.—It is diagnosed from rheumatic arthritis by the fact that the large joints are almost exclusively involved and the disease is far less severe than rheumatoid arthritis. Prognosis.—The prognosis as to life is good; as to perfect re- covery is bad. Treatment.—The indications are— 1. To relieve pain. 2. To relieve stiffness and reduce inflammation. 3. To build up the general health. 1. To relieve pain counter-irritants, and anodyne applications are useful. 2. Stiffness and inflammation are benefitted by massage, elec- tricity and iodide of potassium. 3. Cod liver oil and iron are often useful. Arthritis Deforman. (Rheumatoid Arthritis.) Definition.—A chronic and usually progressive disease affect- ing usually the smaller joints and causing deformity and loss of motor power. Causes.— 1. Age and sex. Women after middle life are usually affected. 2. Menstrual disturbances (Ord) seem to have some influence on its production. 3. Exposure and over-work are said to be causes. Morbid Anatomy.—The articular cartilages are ulcerated and finally destroyed ; the synovial fringes greatly enlarged and thick- ened ; the ends of the bones "eburnated" and sometimes connected 198 PRACTICE of medicine. by fibrous bands and often plates of bone form on the synovial sack surrounding the joints. The adjacent muscles waste. Symptoms.— 1. The smaller joints are usually involved, espe- cially those of the fingers, but the knee, shouhler and other joints may also be affected. The change in the joints from ulceration of the cartilages and disease of the bones leads to deformity. 2. Pain is very great whenever any movement is attempted and often without movement. 3. Arucmia is often present, Diagnosis.—It is distinguished from gout by the absence of the attacks which are so characteristic of gout and of regular tophi in the joints. From rheumatism by the fact that the smaller joints are chiefly affected and there is much greater deformity. (Many physicians however class arthritis deforman and chronic rheumatism together). Prognosis.—The disease is usually progressive and incurable; but recoveries sometimes occur. In the most severe cases there seems to be no tendency to shorten life. Treatment.—A zvarm, dry climate is very beneficial. Cod liver oil and iodide of iron to improve the general health are useful and also arsenic. Hot baths and especially hot douches give good results some- times. Massage and electricity are indicated if they do not cause very severe pam. Myalgia. (Muscular Rheumatism.) Definition.—An affection of certain muscles or groups of mus- cles characterized by pain and stiffness. Causes. — 1. Exposure to cold and dampness is by far the most common cause. 2. Strains will often cause an attack, such as lumbago. 3. Rheumatism and gout and malaria are said to be causes. Morbid Anatomy.—There is no characteristic morbid change. PRACTICE OF MEDICINE. I99 Symptoms.—Pain, especially on movement, and stiffness of certain muscles or groups of muscles, causing—(1) Torticollis or wry neck; (2) lumbago; (3) myalgia of the muscles of the arms and shoulders, &c. Diagnosis.—It is distinguished from (1) disease of the spine by the absence of any disturbance about the vertebrae; (2) locomotor ataxia by the sudden and transitory character of the lightnino- pains in this disease; (3) pleurisy by the absence of fever and pleuritic friction sounds. Prognosis.— The prognosis is always good and the duration usually only a few days. Treatment. —1. To relieve pain by (1) hot applications; (2) cupping: (3) phenacetine; (4) opiates; (5) quinine; (7) electricity. 2. To relieve stiffness by electricity and massage. Gout. Definition.—A disease characterized by an excess of uric acid in the blood and usually by the presence in old cases of deposits of urates (tophi) in the smaller joints. Causes.— 1. Heredity. In a large proportion of cases the dis- ease is distinctly hereditary; no explanation of this fact can be given. 2. Age. It usually occur*, first, especially the acute form, be- tween thirty-five and forty, probably because the causes to be men- tioned next are in more active operation at this period of life. 3. Retention in the body of nitrogenous waste matters from (1) over-eating; (2) defective oxidation; (3) inadequacy of the kidneys. Nitrogenous food is chiefly burnt off to form urea in the liver and if this organ cannot do its work properly, uric acid instead of urea is formed. The formation of urea is a process of oxidation, and the more sedentary the life the less active is this process of oxida- tion. Finally nitrogenous waste is removed chiefly by the kidneys, and uric acid and urate of soda are comparatively insoluble, so if the kidneys are not doing their work properly these substances ac- cumulate in the blood and cause gout. 4. Chronic lead poisoning, even if slight, renders a person far more liable to gout probably by interfering in some way with the action of the kidneys, 200 PRACTICE OF MEDICINE. Morbid Anatomy. — i. The blood contains uric acid in excess. 2. The joints, especially the smaller ones of the fingers and toes, are often enlarged and the cartilages are infiltrated and covered with urate of soda, which in many cases of old standing, forms chalk stones (tophi) around the joints also. 3. The kidneys are often small, their connective tissue is in- creased and urates are found in the urinary tubules. 4. The arteries show ai terio-capillary fibrosis, and the heart is enlarged in consequence. The change in the kidneys and arteries is probably due to the irritation and inflammation seL up by the uric acid in the blood. Symptoms.—A. Prodromic. The symptoms which sometimes (not always) precede an acute attack of gout are, irritability of tem- per, mental depression, flatulence or other dyspeptic symptoms and the presence of large quantities of lithates in the urine. B. During an attack of acute gout. 1. The onset is sudden, the attack usually occurring about 2 o'clock in the morning 2. Nervous. Pain, nearly always in one big toe joint, is by far the most conspicuous nervous symptom. There is great tender- ness as well. 3. The joint affected is swollen, red and exquisitely sensitive. 4. The temperature is elevated 1020 to 1030. 5. The pulse is full and strong and considerably quickened. 6. The digestive symptoms consist in flatulence, heartburn and eructations of gas. 7. The urine shows a great diminution in the amount of uric acid discharged. The duration of such an attack is two or three hours generally, but the joint is left swollen and tender and the attacks are apt to recur every night for ten days or two weeks. C. Of chronic gout. 1. Tophi, or deposits of urates, in and around the joints— ("chalk stones"). 2. Cutaneous. Eczema is a common symptom; it is probably due to the irritation of the skin by the uric acid in the course of its elimination by it. 3. Digestive. Gastro-enteritis is an occasional symptom orform of chronic gout. 4 Nervous. Vertigo, numbness, headache, neuralgia and other nervous symptoms are common. 5. Pulmonary. Bronchitis, according to English physicians, is common. Sequelae.—1. Circulatory. Arterio-capillary fibrosis and hyper- trophy of the heart (see Morbid Anatomy). PRACTICE OF MEDICINE. 201 2. Pulmonary. Asthma is common in the course of gout rather than as a sequel; it is probably due to the irritation of the nerve centers, and possibly of the bronchial tubes themselves, by the uric acid retained in the blood. 3. Digestive. Gastro-intestinal catarrh and jaundice. The for- mer is probably caused by the irritation of the uric acid and the jaundice results from the catarrh. Diagnosis.—It is distinguished from rheumatism by (1) the his- tory of acute attacks; (2) the tophi around the joints; (3) the in- volvment, as a rule, of the smaller joints. Prognosis.—The prognosis is based on (1) the form of the dis- ease—gastro-intestinal attacks in gout are very dangerous; (2) on the age at which it first occurs—the younger the person the worse the prognosis; (3) the complications ; (4) the number of joints in- volved. Treatment.—The indications are— 1. To increase oxidation and thus to have more urea and less uric acid formed. 2. To increase the functional activity of the liver and, at the same time, to lessen the work of the liver. 3. To increase the functional activity of the kidneys and thus elim- inate uric acid. Active exercise is beneficial because it increases the oxidation and the work of the skin which acts vicariously for the kidneys. A zearm climate and zvarm clothing promote the action of the skin and lessen the work of the kidneys. The diet is of the greatest importance ; it should be very scant, especially in nitrogenous food and rich or highly seasoned articles; vegetables, especially those containing little starch, milk, bread and small quantities of meat are advisable. Sweet wines, and most liquors, are especially injurious ; if stimulants are absolutely essen- tial, gin and whiskey are least hurtful. Large quantities of water are useful to wash out the kidneys. Urate of lithia or potash is more soluble than either uric acid or urate of soda, and hence these alkalies are of service. Opium and colchicum may be used to relieve pain. Cold baths to the foot during a paroxysm are not advisable ; warmth is often of service. During an acute attack the foot should be raised, the big toe joint painted with morphia solution or chloral- camphor and then wrapped in flannel. 26 2Q2 PRACTICE OF MEDICINE. Rickets. (Rachitis.) Definition —A disease of infancy and early childhood charac- terized by a defective deposit of lime salts in the bones. Causes.—i. Bad hygienic conditions, especially over-crowding and improper food. ... r . ., -> Probably bad health of the parents, especially of the mother. 3! Age. It nearly always occurs within the first eighteen months or two years of life. Morbid Anatomy.-1. The bones are abnormally soft, the epiphyses are enlarged and the bones often bent. 2 The skull presents striking features ; the fontanels are large, the sutures unclosed and the edges of the bones often greatly thickened. 3. The muscles are thin and flabby. Symptoms.-!. Digestive. The abdomen is usually very large. and flatulence and whitish pasty actions are frequent. The teeth are2CUtThermoasteimportant nervous symptom is laryngismus stridu- lus, but convulsions are not uncommon. 3. The limbs are small, often bent, and the ends of the long bones are enlarged. a The general symptoms are weakness and pallor. Diagnosis.-The diagnosis is based on the appearance of the limbs and skull. Prognosis.—The prognosis depends upon the possibility of re- moving the cause. Treatment.—A. Hygienic. Fresh air and proper food—milk— are of the first importance. , B. Medicinal. Cod liver oil, iodide of iron and lacto-phospnate of lime are the agents which have given best results. Osteomalacia. (Mollities ossium. Malacosteon.) Osteo-malacia is an acquired softening of bones occurring in adult life. It is common in some parts of Europe but rare in America. . ~\n\\M The causes are obscure; it occurs chiefly in women, especially during pregnancy and about the age of thirty-five. The morbid anatomy consists, primarily, in softening ot we bones and secondarily, in certain deformities and fractures resulting PRACTICE OF MEDICINE. 203 therefrom. Malacosteon pelvis is the most important deformity from a practical standpoint. The symptoms are at first, pain in the lower part of the back, which is not characteristic, but which is followed by changes in the bones. The diagnosis is plain. The prognosis is bad and the disease progressive. The only treatment which has been of any avail is the removal of the ovaries and tubes. CHRONIC GENERAL DISEASES. Diabetes Mellitus. Definition.—A disease characterized by the presence of sugar in the urine. If temporary in character it is called glycosuria. Morbid Anatomy.—1. The blood contains sugar, is sometimes thicker than normal and cogulates badly. 2. The liver is hyperaemic. 3. The lungs nearly always contain tubercles, and gangrene is not uncommon. 4. The skin is dry and boils and carbuncles occur very fre- quently. 5. The pancreas has been found diseased (atrophied usually) in a number of cases. Causes.—1. Age and sex. Men in early adult life are most subject to the disease. 2. Nervous troubles, tumors in the 4th ventricle, emotional dis- turbance, or injuries about the head sometimes cause it. 3. Heredity. Diabetes occurs with especial frequency in fami- lies which are liable to nervous troubles. Injudicious eating will add greatly to the severity of the dis- ease. Symptoms.—1. The onset is insidious. 2. Urinary. The amount of urine is nearly always greatly in- creased ; the specific gravity is high—from 1025 to 1040; and sugar is present in greater or less amount; as much as a pound and a half or two pounds may be discharged per day. 3. Digestive. Thirst is excessive, and often there is a ravenous appetite; constipation is present, as a rule. 204 PRACTICE OF MEDICINE. 4. Cutaneous. The dryness of the skin and the frequent occur- rence of boils have been mentioned. 5. Nervous. Neuralgia, especially sciatica, is of common occur- rence; headache and lassitude are also common, and in the late stages coma may come on suddenly or be preceded for a short time by delirium. The coma ("diabetic coma") is probably due to the presence of /3-oxy-butyric acid in the blood. 6. The temperature is often below normal, the pulse weak and the respirations slow. Diagnosis.—The diagnosis is based on the presence of sugar in the urine. Trommer's test for sugar is as follows : Add to the sus- pected urine enough liquor potassae to render it distinctly alkaline, then add a few drops of a solution of cupric sulphate and boil; if sugar be present a red precipitate will be formed. Prognosis.—The prognosis is serious and the disease usually progressive, but life may be prolonged for months or years by pru- dence as to diet. Complications.— 1. Pulmonary. Phthisis is a very frequent complication; pneumonia and pulmonary gangrene also occur. 2. Cutaneous. The boils and carbuncles already mentioned. 3. Urinary. Suppression of urine and uraemia may occur in the late stages. 4. Ocular. Cataract occurs with comparative frequency in dia- betics. Treatment.—A. Dietetic. All saccharine food should be avoided and nearly all starchy food. The following articles of food may be used. 1. Meat of all kinds, except liver; fish of all kinds, except oysters. 2. Bread made of bran, almond flour or soya beans. (Most of the so-called diabetic flour contains starch in large quantity). 3. Butter, cream and fat of any kind. 4. Vegetables. Green vegetables, such as spinach, salads, tur- nip tops, etc. 5. Liquids. Water, buttermilk in moderation, tea, coffee and acid wines. Saccharine should be used in place of sugar; one grain will sweeten a cup of tea or coffee. The following articles should be avoided. 1. All saccharine and starchy food, such as ordinary bread, potatoes and white vegetables, and also beets, turnips, carrots, &c, which contain sugar. 2. All sweet wines and also chocolate. B. Medicinal. The indications are to lessen the amount of sugar discharged and relieve thirst. For this purpose the following PRACTICE OF MEDICINE. 26$ remedies are useful—(1) codeia (or opium in some form); (2) bro- mide of arsenic; (3) carbolic and salicylic acids; (4) antipyrine; (5) lithia water. Diabetes Insipidus. (Polyuria.) Definition.—A disease characterized by the persistent discharge of large quantities of limpid urine. Causes.— 1. Injuries and diseases of the nervous system. 2. Emotional disturbance, if serious and prolonged. Morbid Anatomy.—Often there is none. Sometimes disease of the floor of the 4th ventricle exists. Symptoms.—1. Urinary. The quantity of urine is enormously increased; the specific gravity is low—1004 or 1005. 2. Digestive. Thirst is excessive and constipation usually exists. 3. Cutaneous. The skin is dry and harsh. Diagnosis.—The diagnosis is based on the urinary symptoms, and especially on the persistence of these symptoms and the absence of organic kidney disease, &c. Prognosis and Duration.—Recovery is rare, but patients may live for years with this disease. Treatment.—A. Hygienic and Dietetic. Care should be taken to keep up the general health. No change of diet is necessary ex- cept to diminish the amount of liquid ingested as far as possible. B. Medicinal.—The indication is to lessen the quantity of urine discharged and to allay thirst. The following drugs have been found useful (1) valerian; (2) ergot; (3) salicylate of soda. Antemia and Chlorosis. Definition and Synonyms.—By anaemia is meant a diminution in the number of red corpuscles in the blood. It is sometimes called oligocythaemia. Chlorosis is a form of anaemia usually occurring in girls about the age of puberty without obvious causes. 2o6 PRACTICE OF MEDICINE. Causes.—Anaemia is due to— i. Discharges of blood and pus. 2. The influence of certain chronic diseases, such as phthisis, cancer and Bright's. 3. Malnutrition, from narrowing of oesophagus, &c. The causes of chlorosis are unknown. Morbid Anatomy.— 1. The blood is more vvatery than normal, the number of red corpuscles being only 600,000 or 800,000 per cubic millimeter, instead of 5,000,000. The red corpuscles them- selves are often changed, some being larger than natural, many smaller (microcytes) and some elongated or comet-shaped (poikil- ocytes). 2. The heart, arteries and muscular tissue generally, in severe cases, show some fatty degeneration, and the heart is often enlarged from loss of muscular tone and consequent distension. 3. The skin \s pale; in chlorosis it sometimes has a greenish tinge. Symptoms.—A. The symptoms of acute anaemia from sudden loss of a large quantity of blood are, pallor, faintness, dyspnoea, yawning, restlessness and feeble pulse. B. The symptoms of chronic anaemia and chlorosis are— 1. Cutaneous, Pallor is the most marked. 2. Circulatory. The pulse is soft and compressible, and becomes very rapid on slight exertion. A murmur, often harsh in character, but often blowing, is heard over the heart, most clearly at the 2nd left costo-sternal interspace close to the sternum ; it is propagated a little way to the left, just be- low the clavicle. A blowing sound is heard also over the large veins in the neck ; the cause of these sounds is unknown. Palpitation of the heart is common, especially on exertion. 3. Respiratory. There is dyspnoea on exertion, because the red corpuscles (the oxygen carriers) are diminished in number. 4. Nervous. Headache and hysterical symptoms are common, and are probably due to defective nutrition of the nerve centers. 5. Digestive. Indigestion, which is of frequent occurrence, is due to the want of a proper blood supply to the gastric tubules and the muscular walls of the stomach and bowels. 6. Menstrual. As a rule, the menstrual discharge is diminished, or, more frequently, suspended in cases of anaemia. 7. General. There is no loss of weight, as a rule, in chlorosis. Diagnosis.—The diagnosis of anaemia is perfectly easy. Chlorosis is distinguished from simple anaemia by the absence of any apparent cause in the case of the former. Prognosis.—The prognosis of simple anaemia depends upon the cause. PRACTICE OF MEDICINE. 207 In the case of chlorosis the prognosis is always good, but re- lapses are liable to occur. Complications.—The complications of chlorosis are: 1. Ulcer of the stomach. 2. Pulmonary phthisis; it is questionable whether the anaemia may not be secondary in these cases to the phthisis, which could not at first be detected. Treatment.—The indication is to increase the number red corpuscles in the blood. A. Hygiene and diet. Exercise in the fresh air is very important, because more oxygen is obtained, the circulation is rendered more free and nutrition is increased. The diet should be nutritious and digestible, meat being of es- pecial value. Ale, beer and wine are often of service. Cheerful company and change of air and scene often "work wonders" in chlorosis. B. Medicinal. Iron is the great remedy in these cases, but it acts much better, usually, if given in combination with— 2. Potash. Blaud's pills contain iron and potash. 3. Arsenic is useful especially in chlorosis, 4. Cod-liver oil is of- service if there is much loss of flesh. Progressive Pernicious Anemia. (Pernicious anaemia. Idiopathic anaemia.) Definition. A form of anaemia progressive in course and usually terminating fatally. Causes.—The causes are practically unknown. It is more common in zvomen than in men, and seems to be often connected with pregnancy. Morbid Anatomy.—1. The blood changes are like those of simple anaemia. 2. The marrozv of the bones in many.cases is red, because the fat cells have disappeared, and red corpuscles, usually large and nucleated are found in great numbers. 3. The gastric tubules, according to Fenwick, are often atro- phied. 4. The heart and blood vessels are usually fatty. Symptoms.—1. General. The onset is gradual; there is no emaciation, as a rule, but there is a progressive loss of strength. 2o8 PRACTICE OF MEDICINE. 2. Circulatory. The pulse is soft and compressible and in the late stages rapid and very feeble. Hemorrhages from the nose or other parts are of frequent oc- currence and may be profuse. 3. Ocular. On ophthalmoscopic examination there are found to be hemorrhages into the retina in the majority of cases and vision is more or less impaired in consequence. 4. Digestive. Nausea and vomiting are common and often troublesome symptoms. 5. Temperature. There are irregular rises of temperature, 1020 to 1030 in the late stages. 6. Delirium may occur also at this period. Diagnosis.— 1. From simple aiuernia it is distinguished by its progressive course and the occurrence of hemorrhages. 2. From leucocythcemia by the absence of any increase of white corpuscles in the blood. 3 From Hodgkins disease by the absence of glandular swellings. Prognosis.—The prognosis is extremely bad, and the great ma- jority ot cases terminate fatally. Treatment.—Arsenic is the only remedy which has given any really satisfactory results in this disease. The dose of Fowler's so- lution should gradually be increased up to fifteen or eighteen drops three times a day. Iron, zinc, phosphorous, quinine and various other remedies have been tried without benefit. Leu k/em 1 a. (Leucocythaemia.) Definition.—A disease characterized by a great increase in the number of white corpuscles in the blood and by enlargement of the spleen or lymph glands, or both. Causes.—The causes are practically unknown. Morbid Anatomy.— 1. The blood shows a great increase in the number of white cospuscles, the proportion to the red being I to 60, 1 to 20, or there may even be more white than red (normally the proportion is 1 white to about 300 red.) 2. The spleen is usually enlarged to a greater or less extent, it may be very greatly, the enlargement being usually due to a simple J PRACTICE OF MEDICINE. 209 increase in its normal constituents; but in old cases the amount of connective tissue is increased. 3. The lymph glands frequently undergo a similar change. Symptoms. — 1. Circulatory. The changes in the blood have al- ready been described. The pulse is weak. The spleen and lymph glands are enlarged. Hemorrhages sometimes occur. 2. The skin is pale and occasionally hemorrhages occur into it. 3. The temperature is usually normal till the latter stages of the disease, and then there are irregular elevations, 1020 or 102.5 °. 4. The general symptoms are loss of strength and vigor; there is usually no emaciation. Diagnosis.—The diagnosis is simple and is based on a micro- scopic examination of the blood. Prognosis.—The prognosis is extremely bad; death usually occurs from exhaustion in from three months to three years. Treatment.— Arsenic has given better results than other remedy. Oxygen inhalations have been tried recently with good results. Quinine and iron are useless. Transfusion of blood has been tried without success. Hodgkin's Disease. (Psuedo-leukaemia. Lymphadenoma.) Definition.—A disease characterized by progressive enlarge- ment of the glands in different parts of the body, without increase of white blood corpuscles and by great anaemia. Causes.—The causes are unknov/n. Morbid Anatomy.—1. The lymphatic glands in the neck, axilla, groin, thorax and abdomen are greatly enlarged, hard and occasionally'caseous. Their connective tissue is increased. 2. The spleen undergoes a similar change. 3. Adenoid growths are found in the liver and various other parts. Symptoms.—1. General. Progressive loss of strength and sometimes of flesh. 2. Glandular. The glands are enlarged as already stated. 41 210 PRACTICE OF MEDICINE. 3. Circulatory. The pulse is soft and feeble and hemorrhages sometimes occur. 4. Temperature. There are irregular elevations of temperature in the late stages. Diagnosis—The diagnosis is based on (1) the glandular swell- ing ; (2) the absence of any increase of white corpuscles in the blood. Prognosis.—The disease usually terminates in death ; the dura tion is about a year. Treatment.—Arsenic internally and injected into the growths is said to have given good results. Phosphorus is advised. Cod- liver oil, quinine and iron are useless. Excision of the glands has been tried; it is not usually of service. Addison's Disease. Definition.—A chronic disease, characterized by a bronze color of the skin and usually by disease of the supra-renal capsules. Causes.—1. Age and sex. It is most common in young men or men in middle life. 2. The bacilli tuberculosis are considered the cause by many who hold that the disease is tuberculosis of the supra-renal capsules. Morbid Anatomy.—1. The skin is of a bronze color, especially in the face, hands, and places which are subjected to pressure aud in situations where there is naturally much pigment. 2. The supra-renal capsules are usually diseased ; they may be caseous or have undergone "fibroid degeneration." 3. The spleen is somewhat enlarged in many cases and the lymph glands and Peyer's patches also. 4. The semi-lunar ganglion shows degeneration and pigmenta- tion of its cells. Symptoms.— 1. General. The onset is gradual; there is no emaciation, but a gradual loss of strength, with intervals, however, of apparent, improvement. 2 The nervous symptoms are depression, lassitude and hypo- chondria. 3. The digestive disturbances are nausea and vomiting and there is loss of appetite. PRACTICE OF MEDICINE. 211 4. Circulatory. The pulse is weak and compressible and faint- n< s? may occur on exertion. 5. The temperature is usually normal, but there may be occa- sional elevations. 6. The bronze color of the skin is the most striking symptom. Diagnosis.—It is distinguished from jaundice by the absence of discoloration of the sclerotic. In one case Koch's lymph has been used successfully for diag- nosis. Prognosis.—The prognosis is bad, and the duration usually about eighteen months. Treatment.—Thus far treatment has been useless. Scurvy or Scorbutus. Definition.—A disease characterized by swelling of the gums and by hemorrhagic extravasations in different parts of the body. Causes.—I. Bad hygienic surroundings, probably, predispose to it. 2. Improper food, especially the want of fresh vegetables, is the exciting cause. Morbid Anatomy.—i. The red corpuscles are diminished in number and hemorrhagic extravasations occur in the skin and sometimes in the muscles. The heart is softened. 2. The spleen is enlarged and softened. 3. The gums are swollen and bleed readily and the teeth are loosened. Symptoms.—I. Cutaneous. The skin is pale and bloated and the seat of large or small hemorrhagic extravasations. 2. Circulatory. The pulse is slow, unless quickened by exertion, and is also very weak and compressible. 3. The temperature is usually below normal. 4. Nervous. There is pain in the back and limbs, and the lat- ter are often hard and swollen from extravasation of blood. There is also great depression and loss of mental power. 5. The teeth are loosened and the gums szvollen. Diagnosis.— I. From mercurial stomatitis it is distinguished by the presence of hemorrhagic extravasations in scurvy and by the history of the case. 212 Practice of medicine. 2. From purpura by th* absence of any serious involvment of the gums in the latter. Prognosis.— The prognosis is good. Treatment.—A. Dietetic. Fresh vegetables and lime or lemon juice are both preventive and curative. .,.,.. B Medicinal. The medicinal treatment consists in building up the general health by tonics, such as quinine, iron, quassia and the other a-ents of this class, and by the use of chlorate of potash, which should be taken internally and used as a mouth wash. Solu- tions of carbolic acid, permanganate of potash and boracic acid are also useful as mouth washes. Purpura. Definition.—A disease characterized by either extravasations of blood in the skin and mucous membranes or by hemorrhages from various mucous membranes. Causes.—The causes are practically unknown. The disease sometimes follows rheumatism and diphtheria, but, in the great ma- jority of cases, no cause can be found. Morbid Anatomy.— Extravasations of blood in the skin and mucous membranes are the only morbid appearances in many cases. Small extravasations are but little elevated, but large ones, two or three inches in diameter, are elevated. Symptoms.—A. Prodromic. Occasionally there is a feeling of lassitude and depression before the purpuric spots appear; often there are no prodromata. B. After the spots appear they, or hemorrhages, are usually the only symptoms. Pallor and other symptoms of an.emia result from loss of blood. Pain may occur from distension of the tissues at the seat of ex- travasation. Diagnosis.—It is distinguished from scurvy by the absence of swelling of the gums and of serious constitutional disturbance in the early stages. Prognosis.—In the simple form the prognosis is good ; in the hemorrhagic form it is serious. The duration in simple cases is rarely more than a few weeks; in the hemorrhagic form it may be fatal in a few weeks or may last much longer. Treatment.—A. Hygienic. Rest, fresh air and nutritious food are important. B. Medicinal. The medicines most used are— PRACTICE OF MEDICINE* 2l3 i. Iron, to improve the character of the blood and the nutrition of the walls of the vessels. 2. Sulphuric acid, ergot, turpentine and gallic acid to control hemorrhage. Turpentine and gallic acid are especially useful when there is haematuria. H.emophilia. _ Definition.—A constitutional tendency to bleed profusely from slight injuries. Persons having such tendency are called "bleeders." Causes—1. Sex. Males are more liables to the affection than females ; the tendency usually develops in the first few years of life. 2. Heredity; the transmission is through the mother and not the father. Morbid Anatomy.—There is no characteristic morbid anatomy. Extravasations of blood in the joints, especially the knee joints, is frequent, however. Symptoms—Hemorrhage, from slight injuries, which is profuse and uncontrollable. Prognosis—The prognosis of such cases is always serious. Treatment.—The treatment is purely preventive. Alcoholism. Divisions—1. Acute alcoholism ; (1) Drunkenness; (2) Deli- rium tremens. 2. Chronic alcoholism. Drunkenness will not be considered here. Causes of delirium tremens.— 1. Excessive drinking. 2. A prolonged debauch. 3. Injuries and certain acute diseases, such as pneumonia, will bring on an attack in persons who have been drinking heavily. Morbid Anatomy.—A. Acute alcoholism.—1. The stomach and duodenum are greatly inflamed. 2. The brain, and especially the membranes surrounding it, are congested. 3. The liver, kidneys, lungs and bronchi are hyperaemic. 214 PRACTICE OF MEDICINE. B. Chronic alcoholism.—I The stomach shows the usual evi- dences of chronic inflammation (q. v.). 2. The liver and kidneys are often cirrhotic. 3. The lungs and bronchi—especially the latter—arc inflamed from elimination of alcohol. 4. The brain shows decided changes; the membranes are thick- ened and opaque and the convolutions show an increase of connec- tive tissue. 5. The arteries are usually atheromatous from the action of the alcohol and nitrogenous waste which is retained in the blood. 6. The muscular tissue generally is fatty. Symptoms.—A. Delirium tremens.—1. Nervous. Excitement, with wild delirium at night, first occurs; in the day, for one or two days, the patient has little or no delirium, but after the second or third day the delirium persists, and there are hallucinations usually of a painful or unpleasant character. Sleeplessness always exists. 2. Digestive. There is complete loss of appetite, nausea and vomiting, as a rule. 3. Circulatory. The pulse is rapid, soft and compressible, and prostration is often extreme. An attack of delirium tremens usually lasts three or four days and ends with long and quiet sleep. B. Chronic alcoholism.— 1. Nervous. Tremor of the hands, which is most marked in the morning, want of decision of character and gradual enfeeblement of the intellect, are the most important nervous symptoms. 2. Digestive. Vomiting, especially in the morning, and loss of appetite are nearly always present; in many cases there are evi- dences of cirrhosis of the liver. 3. Circulatory. The pulse is soft and compressible, from fatty degeneration of the heart, unless the arteries are diseased, which they often are. 4. Respiratory. Chronic cough ("drunkard's cough") and more or less dyspnoea on exertion from the bronchial trouble and the weak action of the heart. 5. Renal. The evidences of sclerosis of the kidneys are com- mon in old, standing cases ; the kidneys are "inadequate" and nitro- genous waste is retained in the blood in consequence. Diagnosis.—Profound intoxication is sometimes mistaken for— 1. Apoplexy. In the latter one side is limp and more useless than the other and there is usually no smell of alcohol about the patient (it should be remembered, however, that apoplexy is a re- sult of chronic alcoholism and a vessel may rupture during intoxi- cation.) 2. Uroemic coma. In these cases there is albumin in the urine. 3. Opium poisoning. The pupils are far more contracted in opium poisoning, the respirations usually slower and there is no smell of alcohol. PRACTICE OF MEDICINE. 215 Prognosis.—The prognosis of delirium tremens is usually favor- able, but must always be guarded; if it comes on in connection with pneumonia it is usually fatal. The prognosis of chronic alcoholism depends upon (1) the ab- stemiousness of the patient; (2) the extent of the morbid changes. Sequelae. — 1. Digestive. Cirrhosis of the liver and chronic in- flammation of the stomach. 2. Renal. Bright's disease, especially the cirrhotic form. 3. Circulatory. Fatty degeneration of the heart and sclerosis of the arteries may occur from the changes in the arteries. 4. Nervous. Progressive loss of mental power from the increase of conective tissue in the cerebral convolutions ; multiple neuritis from the action of the alcohoi on the nerves (?); and apoplexy from the changes m the walls of the vessels. Treatment of delirium tremens. The indications are— 1. To sustain strength, which may best be done by nutritious and concentrated food and by the use of digi.alis when the heart's action is weak; alcohol should be avoided if passible, but it is sometimes necessary. 2. To allay the craving for alcohol. Tincture of capsicum and nux vomica are very useful for this purpose; strong beef or chicken tea, made hot with pepper, is also useful. 3. To induce sleep. Paraldehyde, when the stomach will bear it, is best for this purpose. One of the bromides may be given with it with advantage. Opium and chloral are not so safe. 4. To allay excitement quiet is necessary. In the way of drugs, paraldehyde, sulphonal, opium, the bromides and chloral have been used. Depressing remedies should be avoided. 2l6 PRACTICE OF MEDICINE. CHAPTER IX. DISEASES OF THE SKIN. Erythema. Definition.—A hyperaemia or superficial inflammation of the skin characterized by redness, with little or no thickening, as a rule, and by the total absence in all cases of vesicles, pustules and scales. Varieties. — I. Erythema simplex. 2. Erythema multiforme. 3. Erythema intertrigo. Erythema Simplex. Definition.—A hyperaemia of the skin or very superficial in- flammation in which there is no exudate and little or no thickening of the skin Causes.— 1. •'Icchanical irritation from rubbing, pressure, &c. 2. Heat, as from exposure of parts which are usually covered to the sun's rays. 3 Certain chemical irritants, such as chloroform, mustard, some of the aniline dyes, &c. 4 Digestive disturbances, such as the irritation of teething in children (Hyde) and the effects of certain forms of food in some persons. 5. Many drugs, such as antipyrine, belladonna, &c. Symptoms.—Appearance. The skin of the affected part is bright red; there is no swelling and no exudate. There is sometimes considerable burning and itching. Diagnosis.—The diagnosis is based on the superficial character of the affection and the absence of swelling and exudate. Prognosis-—The prognosis is uniformly good and the trouble is of very short duration. Treatment.—Treatment is directed chiefly to the relief of the itching and burning. Dusting powders composed of starch and oxide of zinc or sub- nitrate of bismuth are useful. Sponging with alcohol and water or camphor and water, or with a solution of bicarbonate of soda, often relieves the itching. In many cases of "sun burn" the application of cream gives prompt relief. Parts subjected to pressure should be protected by adhesive plaster. practice of medicine. 217 Erythema Intertrigo. Definition.—A superficial inflammation of the skin where two surfaces lie in close contact. Causes.—1. Heat. It is far more common in hot weather than in cold. 2. Friction. It occurs especially if the two surfaces of the skin rub against each other. 3. Moisture. The accumulation of sweat between the surfaces aggravates, if it does not cause, the trouble. 4. Irritating discharges (urine, and faeces in the case of children, &c.) greatly aggravate the inflammation. Symptoms.—1. The usual seats are the inner surfaces of the thighs, the fold between the buttocks, the under surface of the breasts and the adjacent skin in women, &c. 2. Appearance. There is bright redness, with quite sharply-de- fined borders, and at the bottom of the fold there is often a little crack or fissure in the skin. 3. Secretory. There is considerable moisture, which is due, in part to retained sweat and in part to an exudate, which is said not to stiffen the clothing. The secretion is often quite offensive. 4. Sensory. There is usually considerable burning and itching Diagnosis.—The diagnosis is based on (1) the seat; (2) the ap- pearance ; (3) the absence of much swelling. Prognosis.—The prognosis is favorable, but recurrences are, of course, frequent, unless the cause can be removed. Treatment. — 1. To remove the cause by separating the affected surfaces by absorbent cotton or borated cotton, or by lint smeared with oxide of zinc ointment. 2. To remove secretion by gentle but thorough! washing with tepid water and soap. 3. To allay irritation by dusting powders, of which oxide of zinc and bismuth or starch is one of the best; lycopodium may often be used with advantage. Ointments and lotions are rarely advisable, but the former may occasionally be employed and sometimes the latter. Cleanliness, in the case of children, is very important. Erythema Multiforme. Definition.---An affection of the skin erythematous in char- acter and characterised by great variety in the forms which it may present. 218 PRACTICE OF MEDICINE. Varieties.—The principal varieties are (i) annular; (2) mar- ginal; (3) papular; (4) bullous; (5) nodular. The only one of these requiring special notice is erythema nodosum. ERYTHEMA NODOSUM. Definition.—A form of erythema characterized by swellings of considerable size, often an inch or more in width and two or three inches long, elevated above the surface, red in color, hard at first, subsequently becoming soft, but never suppurating. Causes.—But little is known of any form of erythema multi- forme. Erythema nodosum is most common in early life and in Spring and autumn. It is probably due to nervous disturbance of some kind. Symptoms.— 1. The usual seats are on the front of the tibiae and on the ulnae, but it may occur on the calves of the legs and elsewhere. It is often symmetrical. 2. Size and color. These features have already been described. 3. Sensory. Pain and tenderness are always present in a greater or less degree, and are due probably to pressure on the nerves. 4. General. A general malaise, slight fever and sore throat are common accompaniments. Duration.—The enlargement usually lasts about ten days and then disappears. Diagnosis.—The diagnosis is based on the absence of any his- tory of injury, the symmetrical character of the lesion and the course of the disease. Prognosis.—The prognosis is good. Treatment. — 1. Local. Application of lead lotion is advised. Alcoholic lotions are also useful in many cases. 2. Constitutional. Iron and strychnine have been used with ad- vantage, and also the mineral acids. Disturbances of digestion, if present, should be corrected. PRACTICE OF MEDICINE. 2I9 Urticaria. (Nettle rash. Hives.) Definition.—An inflammatory, non-contagious affection of the skin characterized by the sudden formation of wheals, accompanied by intense itching. Causes.—The essential cause is probably some disturbance of the vaso-motor nerves. The exciting causes are— 1. Irritants, such as the bites or stings of insects. 2. Certain drugs, such as quinine or copaiba, which will cause an attack in some persons. 3. Certain articles of diet, especially shell fish; but some per- sons are affected by other articles, such as strawberries, &c. 4. Exposure to cold will often bring on an attack (Hyde). 5. It may be caused reflexly from disease of other organs, as the kidneys, uterus, &c. It is sometimes associated with or alternates with attacks of asthma. Pathology and Morbid Anatomy.—The disease is almost cer- tainly due to vaso-motor disturbance. The wheals contain a sero- fibrinous exudate which compresses the vessels and forces out the blood. Symptoms.— I. The onset is sudden, the wheals suddenly ap- pearing and as suddenly disappearing. 2. The zvheals vary from the size of a finger-nail to the diame- ter of an inch or, rarely, more. They may appear on any part of the body except the face, scalp and soles of the feet. In color they are usually white with a reddish border. In number, there may be but one or two or the body may be covered with them. 3. Sensory. Itching is intense, probably in consequence of the irritation of the peripheral nerves. Diagnosis.—The diagnosis is based on the appearance and itching, and on the sudden occurrence and equally sudden disap- pearance of the wheals. Prognosis.—The prognosis is good in acute cases ; in chronic cases it is very rebellious to treatment. Treatment*—I. To remove the cause by (i) correcting digestive disturbances with calomel, alkalies, the mineral acids, nux vomica; (2) preventing irritation of the skin by rough flannels. 2. To relieve itching by (1) bromides, antipyrine, &c, internally, and (2) by chloral solutions, camphor, starch, bismuth, fluid extract of grindelia robusta, lime water, &c. externally. 220 PRACTICE OF MEDICINE. Eczema. Definition.—An inflammatory affection of the skin characterized by redness and the formation of papules, vesicles, pustules or scales. As a rule, these lesions are more or less combined in each case. Forms.—The disease may be (i) acute, or (2) chronic. Causes.—The causes are exceedingly obscure. Some persons are predisposed to eczema, but it is not known in what this predis- position consists. Irritants, such as rough clothing, exposure, scratching, and va- rious other things may occasion it. Certain plants, as poison oak and poison ivy, will induce it. Dyspepsia will sometimes bring on an attack, and gouty persons seem to be especially liable to it. Asthma is a common complica- tion. Morbid Anatomy.—Eczema is an inflammatory condition, and there is redness, heat and swelling, as in all other inflammations. The exudate may be fibrinous, as in the papular variety, serous in the vesicular, purulent in the pustular; in the squamous form, which is very chronic usually, the amount of exudate is too slight to be perceptible, but sometimes the skin is thickened and there is often atrophy of the sweat glands and hair follicles. Symptoms.—1. The appearance depends upon the form (pap- ular, vesicular, pustular or squamous). There is redness of the skin always. In the papular form, small papules appear on a reddened base. In the vesicular, little vesicles filled with serous fluid are seen. In the pustular form there are little pustules. In the squamous form the skin is thickened and scaly. 2. The seat and extent of eczema varies greatly in different cases; it may occur on any part of the body; the head and face is a favorite seat in the case of children; the hands, genital organs and anal region are often affected later in life. The extent varies also very greatly; the patch may be not more than an inch in di- ameter or a large part of the body may be affected. 3. Secretory. In all, or nearly all, cases at some time in their course there is more or less secretion; in acute cases it is usually abundant, in chronic cases, scant. If the secretion (or exudate) is serous it dries into scales, if purulent, into thick and friable scabs. 4. Sensory. Itching is a prominent symptom in all cases, and sometimes is so violent as to cause intense annoyance. Diagnosis.—Eczema is distinguished from (1) acne by the more superficial seat of the inflammation and the greater prominence of the itching in the former; (2) impetigo by the absence of itching, as a rule, in this disease, and the larger size and more scattered ar- PRACTICE OF MEDICINE. 221 rangement of the pustules; (3) scabies by the presence of the bur- rows and parasites peculiar to this disease. Prognosis.—The prognosis, as to life, is always good; the du- ration exceedingly uncertai 1 and relapses frequent. Treatment.—The treatment depends upon the stage of the dis- ease, but even in cases apparently similar in all respects remedies which are efficacious in one will fail in another. The first indication, which holds good in all cases, acute and chronic, is— 1. To remove the causes of the disease and all sources of irrita- tion, such as (1) local irritants, coarse flannel or friction from any cause; (2) frequent washing of the inflamed spots, especially with strong soaps; (3) disturbances of the digestive organs. Bismuth and the alkalies are useful in many cases. 2. To remove crusts, when present, by poultices or oily applica- tions. 3. To relieve inflammation and allay itching— A. In acute cases by sedative applications, such as (1) Carron liniment; (2) ointment of subacetate of lead; (3) menthol dissolved in sweet oil; (4) fluid extract of grindelia robusta; (5) a paint made of bismuth and glycerine ; (6) oxide of zinc ointment, sometimes diluted; (7) carbolic acid and sweet oil (1 or 2 grains to the ounce) ; (8) powdered starch ; (9) powdered boracic acid alone, or combined with bismuth or starch; (10) oxide of zinc and starch or bismuth. , B. In chronic cases, by more or less stimulating applications, such as (1) tar ointment; (2) oil of cade diluted with olive oil; (3) green soap ; (4) icthyol ointment; (5) sulphur ointment, &c. Arsenic should never be used internally (or externally) in the acute forms of eczema; in the chronic forms it is often very useful. Impetigo. Definition.—An inflammatory affection of the skin character- ized by the formation of discrete pustules, the size of a coffee bean or larger. The disease is non-contagious and is by many considered to be a form of eczema. Causes.—Irritation, by scratching with dirty finger nails, is probably a cause. 222 PRACTICE OF MEDICINE. 2. Age. The disease is most common in children and young adults. 3. Season of the year. It occurs generally in the autumn. Morbid Anatomy.— 1. Size and shape. The pustules arc the size of a coffee bean or larger, rounded or oval in sliape and ele- vated above the surface of the skin. 2. The exudate is purulent. Symptoms.—1. The characters of the pustules have just been stated. 2. The numbers vary exceedingly, usually there are only eight or ten. 3. The usual seats are on the face—especially about the mouth —and on the feet. 4. The surrounding skin is not inflamed, as a rule, but in ecthy- ma, which is now often considered a form of impetigo, there is a red areola around the pustules. 5. Sensory. Itching is not usually prominent. 6. Terminations. The pustules dry up and form scabs or crust; sometimes they rupture. Diagnosis.—From ordinary eczema, by the absence of great itching and of a vesicular stage and by the scattered arrangement of the pustules: (sometimes, however, especially around the mouth, they merge into each other). Prognosis and Duration.—The prognosis is good ; the dura- tion rarely more than a few weeks. Treatment.—The treatment consists in— I. The evacuation of the'pus. 2. The use of antiseptic lotions or ointments containing corrosive, sublimate, carbolic acid, resorcine, boracid acid or some agent of this class. Lichen Planus. Definition*—An inflammatory, non-contagious affection of the skin characterized by the formation of raised, flat patches of a deep purple color, glistening in appearance and but slightly desquama- tive. Causes.—1. Probably it is intimately connected with some ner- vous disturbance, as it is often associated with neuralgia. 2. Age. It is most common in early and middle adult life. 3. It is not contagious. PRACTICE OF MEDICINE. 223 Morbid Anatomy.—1. The hair follicles are primarily involved, the inflammation commencing in the outer layer of the root sheath (Hyde). 2, Papules are formed first and the flat-raised spots are formed by coalescence of the papules. Symptoms. —1. Characteristics of the rash. Flat papules from the size of a pin's head to that of a split pea, deep purple 'color glazed, umbilicated, with but little tendency to desquamation and pursuing a very chronic course and leaving a pigmented spot. 2. Seat and extent. They may occur at any part of the body, are most common about the flexor surfaces of the wrists and knees' and may be widely distributed. 3. Sensory. The itching is usually moderate, but is sometimes quite severe. Diagnosis.—The diagnosis is based on (1) the polygonal shape; (2) the purple color; (3) the umbilication. Course, Duration and Prognosis.—The course is chronic, the duration often many years and the prognosis, as to life, good, but as to permanent recovery, not very favorable. Treatment.—A. General. 1. Arsenic is very useful in most cases, especially the very chronic ones. 2. Tonics. Cod liver oil, iron, zinc, &c, are useful. B. Local. Ointments of (1) corrosive sublimate; (2) carbolic acid; (3) tar; (4) icthyol; (5) thymol; (6) chrysophanic acid. Lichen Ruber. The disease is, in appearance, much like the one just described, except that the eruption has a "marked tendency to generalization and the induction of a fatal marasmus" (Hyde). The eauses of the disease are unknown. The symptoms in" the beginning are like those of lichen planus, but later on the skin becomes greatly thickened and cracks and is covered with scales. The diagnosis is based upon the symptoms named. The prognosis is always serious. The treatment consists in the administration of arsenic, tonics and good diet, and the local use of remedies to allay irritation, 024 practice of medicine. Prurigo. Definition and Frequency.—A very rare affection of the skin, chronic in character and characterized by the occurrence "on the exterior surfaces of the limbs and on the trunk of minute, pale or reddish papules with extensive infiltration and intolerable itching." Causes.—I. Prevalence. The disease is very rare and is con- fined chiefly to Austria (Hyde). 2. Bad hygienic conditions are undoubted causes. 3. Age. It begins, usually, in infancy, and persists through life. 4. It is not contagious. Symptoms. —1. Characteristics of the rash. Papular, pale or reddish in color, with extensive infiltration. 2. Seat and extent. The external surfaces of the legs and thighs or of the arms are affected first; the trunk later. The glands are frequently enlarged. 3. Sensory. Itching is extremely severe, and interferes with sleep and rest so much as to lead occasionally to insanity. Diagnosis. —1. From eczema by the seat, uniformity of the rash and the obstinate course. 2. From scabies by the absence of burrows and the seat. Prognosis.—The prognosis, as to recovery, is bad; it usually lasts through life. Treatment.—1. General. To improve the general health as far as possible by fresh air, good food and tonics. Arsenic is not advisable. 2. Local. Sulphur, tar and green soap have been used with some relief. Pityriasis Ruhka. (Exfoliative Dermatitis.) Definition and Frequency.—A very rare, chronic, inflamma- tory affection of the skin characterized by redness and profuse scaling and by more or less itching. Causes.—The causes are unknown. Morbid Anatomy.—The chronic inflammation leads to increase of connective tissue and atrophy of the glandular structures and hair follicles. PRACTICE OF MEDICINE. 225 Symptoms. — Characteristics of the rash. Bright red in color and marked by the exfoliation of innumerable scales. No exudate unless the skin cracks at the joints, as it sometimes does. 2. Sensory. Itching varies in degree; it is often severe. Diagnosis.—1. From eczema by the absence of exudation^ vesicles or papules at any time. 2. From psoriasis by the diffuse character of the rash. Prognosis and Duration.—The prognosis is serious, as to life, in bad cases, the disease often leading to nephritis, and the duration is usually life long. Treatment.—No internal medication has done any good, as a rule; in a single case, carbolic acid, one drop at a dose, was appar- ently beneficial. Locally, vaseline is comforting. Psoriasis. Definition and Frequency.—A chronic, non-contagious, in- flammatory affection of the skin characterized by the formation of flat papules covered with white scales. It is one of the most frequent of the skin diseases. Causes.—The causes are unknown ; it occurs at all ages, after infancy, and in both sexes. Symptoms and Signs.— 1. Characteristics of the rash. Flat papules from i^th to y2 inch in size, red in color, but covered with white scales. 2. Seats and extent. The most common and earliest seats are on the posterior surface of the elbows and the anterior surface of the knees; it is seen also on the limbs, back and face. 3. Sensory. Itching is not usually marked. Constitutional symptoms are absent. Diagnosis.—1. From eczema by the absence of moisture at any period and the absence of itching to any marked degree. 2. From pityriasis—(See Pityriasis). Prognosis.—The prognosis, as to life, is always good, but the duration is uncertain and relapses are certain. Treatment.—A. General. Arsenic is most useful. Cod liver oil and iron in case of debility. B. Local. Tar ointment, pyrogallic acid ointment, (1 drachm to 1 ounce) chrysophanic acid ointment (5 to 10 grains to \ ounce), hot baths and soap. ........ r 28 226 PRACTICE OF MEDICINE. Pemphigus. Definition and Frequency.—A rather rare, acute or chronic affection of the skin, characterized by the formation of bullae from the size of a bean to that of an egg. Causes.—The causes are practically unknown. The disease is not contagious and is most frequent in children. Syphilis will cause a bullous eruption, which is not usually classed with pemphigus. Symptoms.— I. Characteristics of the eruption. Papules soon succeeded by bullae varying in size and containing serous, rarely sero-purulent or bloody, fluid. 2. Seats and number. The bullae may occur at any part of the surface, and there may be only a few bullae or a hundred or more. 3. Sensory. Itching is slight in most cases, but is rarely very troublesome. 4. Constitutional symptoms—fever and sometimes prostration. 5. Termination. The usual termination is in drying and crust- ing, but the bullae may burst and form sores. Diagnosis based on the presence of bullae. In infants newly born, the disease is nearly always syphilitic. (Pye-Smith). Prognosis.—The prognosis is serious in infants and old persons; favorable in others. Treatment.—A. General. Arsenic is most useful; tonics and iodide of potassium, if necessary. B. Local. Of little value ; oxide of zinc ointment has been ad- vised. Herpes Zoster. (Shingles. Zona). Definition.—An affection of the nerves, nerve centers or gan- glia, characterized by the formation on the skin of firm, distended vesicles, limited to an area supplied by one or more twigs of a cra- nial or spinal nerve. Causes.— 1. The essential cause is an inflammation of the nerve, sensory nerve root or ganglion. 2. Age and sex have but little influence. 3. Cold and dampness seem to be causes occasionally. 4. Injuries involving a nerve may cause an attack. PRACTICE OF MEDICINE. 227 Symptoms.—1. Characteristics of the eruption. Maculae first appear, which are soon followed by vesicles as large as a pea or smaller, containing serum usually, but sometimes pus or blood. 2. Seats and extent. The body (intercostal nerves), face, head, eyes, arms, genital organs, &c, may be involved. The eruption is limited to the area of distribution of one or two nerve twigs. 3. Nervous. Neuralgia is nearly always present; it may pre- cede the eruption and be very intense; tenderness is also present; there is little or no itching, but may be numbness and various parsesthesiae. 4. Constitutional symptoms—fever, anorexia, &c.—are rare, but may occur. 5. Terminations. The vesicles rarely burst, but usually dry up and form a scab which finally comes off and leaves a.scar. Diagnosis.—From eczema by the thickness of the wall of the vesicle, the absence of itching and the presence of neuralgia. Prognosis usually favorable, but occasionally the disease persists and the patient is worn out by suffering. The usual duration is two or three weeks. Treatment.—A. General. Phosphide of zinc and extract of nux vomica, quinine, strychine and arsenic have been used. B. Local. Oleate of morphia, oleate of zinc, menthol dissolved in olive oil and various dusting powders containing oxide of zinc, &c, have been used ; the object is to relieve pain. Galvanism sometimes does good. The skin should be protected from rubbing. Herpetic eruptions are of common occurrence on the lips (in fevers) and on the genital organs ; they are of little moment. Icthyosis. Definition.—A deformity of the skin appearing in the first years of life (and probably congenital) characterized by the forma- tion of scales or plates of horny consistency. Causes.—1. Age. It is almost certainly congenital, but appears usually in the first year of life. 2. Heredity appears to be a cause, but opinions differ on this point. 228 PRACTtCE OF MEdlCINE. Symptoms and Signs.—i. Appearance. The skin may be sim- ply very dry, with slight scaliness, or the scales may be thick and in poligonal masses. In still more severe cases the skin may be horny from the development of the papillae. 2 Scats and extent. The most common seat is on the extensor surfaces of the limbs and on the back, but nearly the whole body may be affected—the face and genital organs least. 3. Secretory. There is little or no secretion of sweat. 4 Sensory symptoms are not usually marked. 5 Constitutional symptoms are also slight or entirely absent; occasionally growth seems to be partially arrested by it. Diagnosis.—The diagnosis is based on the symptoms and the absence of inflammation. Prognosis.—The prognosis, as to life, is good ; as to recovery, bad. Treatment.—A. General. The affection is a deformity, and internal treatment is unavailing. A warm climate to stimulate the function of the skin is advisable. B Local. Baths, alkaline or simple, are useful in order to soften and remove the scales; after bathing, ointments, either sim- ple vaseline or some bland ointment, are useful, and also the glyce- role of starch. Scleroderma and Morphcea. Definition and Frequency.—Scleroderma is a more or less chronic disease, characterized by hardening of the skin over exten- sive areas. . Morpluxa is an affection of the skin, characterized by a gradual hardening in patches. Both diseases are extremely rare. Causes.—1. Both diseases (they are probably different forms of the same disease) are tropho-neuroses. 2. Age. The affections are most common in young adults, but may occur at any age. 3. Sex. Women are far more liable to this disease than man. Morbid Anatomy.—In scleroderma there is a gradual increase of connective tissue in the corium and sub-cutaneous tissue. In morphcea there is a similar change, less generalized. PRACTICE OF MEDICINE. 22CJ Symptoms.—1. Appearance. The skin in scleroderma becomes whitish in color; in morphcea there may be redness or yellowness at first, and sometimes pigmentation. 2. Seat and extent. Scleroderma may involve large surfaces, the face and neck are usually involved first. Morphcea occurs in patches, often on the distribution of a nerve. 3. Nervous. Various paresthesia may be present in cases of morphoea. Stiffness is troublesome in bad cases of scleroderma, from increase of connective tissue. 4. Temperature. The temperature over the affected spots is de- pressed, because of the anaemic condition. 5. Termination. Often recovery occurs most unexpectedly. Death may occur from marasmus, or from stiffening of the jaws (Fagge.) Diagnosis—The diagnosis is simple. Prognosis.—The prognosis is uncertain and the duration variable. Treatment.—A. General. Nerve tonics such as cod liver oil, iron, quinine and strychnine are advised. Arsenic has been found useful. B. Local. The galvanic current has given good results in a number of cases. Massage, baths and mercurial ointment are recom- mended (Duhring). Lupus Vulgaris. Definition.—A very chronic tubercular affection of the skin, characterized by redness and the formation of nodules and ulcers. Causes.—1. The bacillus tuberculosis (see Tuberculosis) is the essential cause. 2. Age. It commences as a rule in childhood. 3. Sex. Females are affected oftener than males. Morbid Anatomy.— 1. The bloodvessels are engorged, causing redness, and tubercles are formed underneath the epidermis. Ulcer- ation occurs at a later stage. 2. The exudate is purulent and rather scant, forming yellowish crusts or scabs on the ulcers. 3. The tubercles, unlike those in ordinary tuberculosis else- where, are rich in blood vessels (Green). 230 PRACTICE OF MEDICINE. Symptoms.— I. Appearance. Redness, more or less bright and ending quite abruptly; firm elevations, later on ulcers covered with crusts. 2. Seat and extent. The face is usually involved, and especially the nose, but it may occur elsewhere. The size of the patches varies from an inch to five or six inches in diameter. 3. Sensory. Sensory symptoms are absent, as a rule. 4. There are no constitutional symptoms, as a rule, either, un- less complications exist. 5. Termination. Cicatrization often occurs at one point while it is spreading at another ; the cicatrices are usually soft and superfi- cial. Diagnosis.—The diagnosis is usually easily made; in doubtful cases Koch's lymph has been used to decide the matter. Prognosis and Duration.—The prognosis as to life is good, as to recovery bad; the duration usually being many years. Treatment.—A. General. Tonics, such as cod-liver oil, iron and hypophosphites are advised. The injection of Koch's lymph (tuberculine) has recently been employed with apparently curative results, but its value is not pos- itively determined. B. Local. Incisions, punctures and the galvano-cautery have been used to destroy the blood vessels and cause an atrophy (?) of the tuberculosis tissue. Scraping out the ulcers is also practised with benefit. Ointments of sulphur, mercury, pyrogallol and other substances have been employed. Lupus Erythematodes. Lupus erythematodes is probably a more superficial form of lupus vulgaris, in which nodules form, but no ulcers. It occurs usually in middle life, commonly in women, and the usual seat is on the nose and checks, but it may be extensively distributed. It is character- ized by redness and the formation of thin scars without ulceration. It lasts for years. The treatment is like that of lupus vulgaris. PRACTICE OF MEDICINE. 231 Leprosy. (Lepra. Elephantiasis Graecorum.) Definition.—An infectious disease, very chronic in course, and characterized by the formation of nodules on the skin, larynxj &c, or by neuritis, with anaesthesia, and later by ulceration. Varieties.— 1. Tubercular. 2. Anaesthetic. Causes.—1. A germ. The bacillus leprae, which is precisely like the bacillus tuberculosis (q. v.) except that it stains more readily (Crookshank) and inoculation with it does not cause tu- berculosis. 2. The mode of conveyance is probably in the secretions. 3. The avenue of introduction is not known. 4. Males, in middle life, are rather more subject to the disease than others. 5. Distribution. The disease occurs in the Sandwich Islands, China, Japan, India and a number of other countries ; it is rare in America and England. Morbid Anatomy.—1 In the tubercular form elevations, nod- ules are formed the size of a bean or very much larger, consisting chiefly of granulation tissue, with some blood vessels; these nodules occur in the skin and mucous membranes, notably in the larynx, and they mav ulcerate and sometimes cicatrize. 2. In the anaesthetic form there is a neuritis, involving one or more nerves and leading to atrophic changes in the skin and muscles. Symptoms.—A. Prodomic. Attacks of fever and digestive disturbances, depression and anorexia of variable duration and at variable intervals. B. Of the developed disease— 1. Appearance. There may be (1) nodules (or tubercles), vary- ing in size from that of a bean to a tomato—yellowish or reddish in color, or (2) maculae, of reddish or white color, or (3) large sur- faces of skin looking white and atrophied Later, contraction of the eyelids, cheeks, lips and other parts, and ulceration leading to loss of fingers or toes or the entire hand may occur. 2. Seat and extent. The most usual seat of leprosy is on the face or hands, but other parts of the body may be affected. 3. Sensory. Various paraesthesiae occur and later complete anaesthesia. 4. Constitutional. There is a gradual loss of strength. Diagnosis.—The diagnosis is based on the character of the lesions and their great chronicity, and on the bacillus leprae. 232 PRACTICE OF MEDICINE. Prognosis.—The prognosis is uniformly bad ; the duration in the tubercular form from eight to ten years, in the anesthetic form from fifteen to twenty years. Treatment.—A. Prophylactic. Isolation, to prevent a further spread. B. Remedial. Change of residence to a country where the disease does not prevail; tonics are suggested, but have little effect. Baths and antiseptic ointments are often of service. Acne. Definition.—A chronic, inflammatory affection of the sebaceous glands and peri-glandular tissue, characterized by the formation of small papules or pustules. It is probably the most common of all skin diseases. Causes-—I. Age and sex. It usually occurs about the age of pubertv and is rather more common in boys than in girls. 2 Possibly irritation of the skin may cause it. 3. Certain drugs—the bromides and iodides—will bring on acne, when taken for any length of time. Morbid Anatomy.—The sebaceous glands and the peri-glan- dular tissue is inflamed and then results redness and swelling. The exudate may be serofibrinous or purulent, usually it is pur- ulent. Symptoms.—I. Anr-earance. The eruption is red in color, but often becomes yellow (when pus forms) and frequentlv a black spot is seen in the centre of the bump, in consequence of the stopping of the mouth of the follicle with foreign matter. The bumps vary in size from ^ inch to \ inch in diameter. 2. Seat and extent. The usual seats are on the face and between the shoulders. There may be only a few bumps or the face may be covered with them. 3. Sensory symptoms are absent, as a rule, but there may be some sensitiveness. 4 Constitutional symptoms are often absent, but there may be anaemia and various digestive disturbances. 5 Terminations. As a general rule, no scars are left, but in se- ver^ <-ases thrre mav be extensive pitting. Diagnosis.—The diagnosis is based on the character of the eruption and the absence of sensory symptoms, PRACTICE OF MEDICINE. 233 Prognosis and Duration.—The prognosis is good ; the dura- tion often several months. Treatment.—A. General. To correct any disturbance of the general health by purgatives, if constipation exists, and by cod liver oil, iron and other tonics if there is anaemia or debility. B. Local. Pus should be let out by small punctures and pres- sure; the skin should be thoroughly rubbed with a towel wrung out of hot water and solutions of bichloride of mercury (1 grain to the ounce), sulphide of potassium (1 drachm to 4 ounces) or oint- ments of sulphur (}4 drachm to I ounce of vaseline) or resorcine (10 to 20 grains to the ounce of vaseline) should be applied. Acne Rosacea. Definition.—A chronic affection of the skin occurring chiefly on the face—especially on the nose—and characterized by passive hyperaemia and subsequently by more or less enlargement fiom increase of connective tissue and inflammation of the sebaceous follicles. Causes.— I. Uternic or ovarian disturbance in women, espe- cially at puberty and the menopause. 2. Alcoholic liquors. 3. Exposure to heat or cold. Symptoms.—1. Appearance. First there is simply redness of the affeeted part; later, large vessels may be seen in the skin and still later there may be great hypertrophy of the part with the for- mation of nodular masses. Ulceration and scab formation are never observed. 2. Seat. The most common seat is the nose, but the cheeks and the forehead may also be involved. 3. Sensory symptoms are absent; constitutional symptoms of va- rious kinds may occur from the causative condition. Diagnosis.—It is distinguished from other skin diseases (syph- ilis and lupus) by the absence of crusts or ulcers. Prognosis and Duration.—The prognosis of the mild form or in the early stage is good ; when nodular masses have formed there is no possibility of their removal except by surgical means. The duration depends on the form. Treatment.—A. General. The chief object of general treat- 30 2^4 PRACTICE OF MEDICINE. ment is to lessen the amount of blood in the face. Alcoholic liquors should be forbidden, a scant diet advised, disturbances of the uterine functions corrected and purgatives should be administered if there is constipation. B. Local. To cause contraction of the dilated vessels and stimu- late the skin by sulphur ointment or solution, green soap, alcoholic solution of corrosive sublimate (i grain to the ounce), &c.; or to destroy the crilarged vessels by galvano puncture or puncture with a small knife. , Sycosis. Non-parasitic sycosis is a rare disease characterized by an inflam- mation of the hair follicles and the formation of papules or pustules. The causes are unknown. It occurs on the face—on the chin, cheek or upper lip—and causes considerable burning pain. A hair rises from the center of each papule or pustule. It is distinguished from eczema by its seat and the absence of itching, and from parasitic sycosis by the absence of a parasite. The disease persists for a long time if not properly treated. The treatment consists in the administration of cod liver oil, iron and arsenic, shaving and the application of oxide of zinc ointment in the acute cases or of sulphur ointment at a later period. Tinea Circinata. (Ring worm.) Definition.—A parasitic affection of the skin, contagious and characterized by more or less circular, squamous, vesicular, papular or (rarely) pustular spots. Causes.—i. The essential cause is a parasitic plant, the tinea trycophyton, composed of cells secured end to end in such a way as to form long and branching plants. It forms spores from which new plants develop in about twelve days. 2. Heat and moisture are favorable to the growth and develop- ment of the plant. 3. The disease may be transmitted from animals. PRACTICE OF MEDICINE. 235 4. Age. It is more common in children than in adults, but may occur at any age. 5. It is highly contagious. Morbid Anatomy—The trycophyton grows between the super- ficial layers of the epidermis. Symptoms—1. Seat and extent. It may occur at any part of the body, but is especially common on the face and thighs. When the scalp is attacked it is called tinea tonsurans; when it involves the follicles of the beard it is known as parasitic sycosis. A patch is rarely more than 3 or 4 inches in diameter and is usually much less. 2. Appearance. Patches of tinea circinata are circular in outline, reddish in color, papular, vesicular, rarely pustular, but most fre- quently scaly—the scales being small and branny. In tinea tonsurans the hair is lost and baldness in patches results. 3. Sensory. As a rule, there is little itching, but it may be intense. Eczema marginatum is a form of ring worm occurring usually on the buttocks and thighs, but sometimes on other parts of the body, and characterized by a red, sharply-defined and usually elevated ring, which gradually extends and is attended with violent itching. Diagnosis.—It is distinguished from psoriasis, eczema and all other eruptions by a microscopic examination, when the tricophyton can readily be seen. Prognosis.—The prognosis is good, but eczema marginatum is often tedious and obstinate. Treatment.— 1. To remove all scales by thorough bathing and rubbing with soap and water. 2. To destroy the parasites by applying tincture of iodine, bichlo ■ ride of mercury solution (1 grain to the ounce), thymol or boracic acid solutions and ointment of nitrate of mercury (30 grains to the ounce) chrysarobin or pyrogallol (5 to 10 grains to the ounce of vaseline). Scabies. (Itch.) Definition.—An inflammatory and highly contagious affection of the skin caused by the itch parasite (acarus scabiei). Causes.__1. The essential cause is an animal parasite—the aca- rus scabiei—zhout TVth of an inch in length and oval in shape. 236 PRACTICE OF MEDICINE. The females only, penetrate the skin, the male, which is much more short-lived, remaining on the surface. 2. Want of cleanliness is a frequent, but not an invariable, cause of scabies. 3. Age and sex. Children are more liable to the disease than adults and men more than women, because they are brought into more intimate contact with each other. The disease is very contagious—the parasites readily passing from one body to another. Symptoms —1. Seat and extent. All parts of the body may be attacked, t,_ie fingers and clefts between the fingers, the toes, the axillae, the bre-ists in women and the penis in men are most liable to be attacked—the face least liable. 2. Appearance. Papules, vesicles or occasionally pustules may be formed, but the characteristic lesion is a burrozu in the skin made by the parasite, and containing eggs—1 dozen or more—black spots (faecal matter) and at one end a white spot—the itch mite—which may be removed with a needle and examined under the microscope. 3. Sensory. Itching is usually excessively severe, especially at night, because the warmth of the bed renders the nerves more irritable. Diagnosis.—The diagnosis is based on (1) the burrows; (2) the situation of the eruption; (3) the presence of the parasite. Prognosis.—The prognosis is always good. Treatment. — 1. Thorough cleansing of the surface with soap and water to remove all obstacles to the action of parasiticides. 2. The application of parasiticides, such as an ointment of sulphur, 6d grains, Peruvian balsam, 120 grains, and vaseline, one ounce- applied every night for three days ; this treatment is practically certain to effect a cure. PRACTICE OF MEDICINE. 237 CHAPTER X. DISEASES OF THE NERVOUS SYSTEM General Symptomatology of Diseases of the Nervous System. Disturbances of Motion.—A. Motor irritation may show itself in the form of—1. Spasm. 2. Tremor. 3. Ataxia, or loss of co- ordinating power. Spasm or convulsions may be (1) direct, when the irritation causing them is applied directly to the motor centre or centres, or to the motor nerve, or to the muscles themselves ; or (2) reflex, when spasm is due to an irritant applied to a distant point, the impression then being conveyed to the nerve centre and reflected to the muscles. Spasms are said to be tonic when they are continuous for a greater or less length of time. They are called clonic when they are interrupted or jerking in character. They are classified, also, according to the extent of the spas- modic movements ; for example, the spasms mav be (1) general, as in tetanus and strychnia poisoning; (2) confined to one side of the body (hemi-spasm); (3) a single muscle may be affected (mono- spasm), or (4) a number of muscles may be affected irregularly, as in chorea, &c, &c. By tremor is meant a tremulous motion of different parts of the body from muscular contractions of very slight excursion. It may be constant as in paralysis agitans or occur only when the per- son tries to move, as in insular sclerosis; this latter form is some- times called "tremor of intention." By ataxia is meant a loss of the power to move different mus- cles together and in harmony with each other, as in locomotor ataxia. B. Weakness or loss of motor pozver. There may be simply a weakness of motor power, which is called paresis, or a complete loss of power, which is called paralysis. The extent and distribution of paresis or paralysis varies in different cases. For example, hemiplegia is paralysis of one late- ral half of the body, paraplegia is paralysis of the lower limbs and lower part of the trunk, monoplegia is paralysis of a single muscle or group of muscles. The general causes of paralysis are— 1. Certain lesions of the motor centres in the brain, due to hem- orrhage embolism, tumors, &c. Paralysis from this cause is not attended by any sensory disturbance, as a rule, it varies in extent and is frequently followed by secondary degenerations, q. v. 238 practice of medicine. 2. Certain lesions affecting the motor tracts in the brain or cord. Lesions of these tracts, as a rule, cause hemiplegia (not mono- plegia) and are frequently attended by disturbance of sensation hemi-anaesthesia) because the motor tracts occupy the anterior two-thirds of the posterior limb of the internal capsule and the sensory tracts the posterior third and the internal capsule is a com- mon seat of hemorrhage. 3. Disease and loss of function of the large multipolar cells in the anterior corriua of gray matter. 4. Certain injuries or diseases of the motor nerves, such as sec- tion of a nerve and neuritis. In these cases there is a degenerative change in the nerve fibres and in the muscles which they supply. Sensation is more or less affected if the nerve be a mixed one, and the paralysis is of limited extent, but several groups of muscles may be involved, as in multiple neuritis. 5. Certain poisons, such as lead and arsenic. They probably act by setting up a neuritis. 6. Certain acute infectious diseases, such as diphtheria and ty- phoid fever; they also probably cause neuritis. 7. Certain reflex forms of paralysis have been described, but it is very doubtful whether such cases occur. 8. Certain cases ot hysteria; this is a common cause ot paraly- sis, and it may be limited in extent or quite extensive. Distur- bances of sensation often accompany the paralysis, but there are no trophic disturbances. Disturbances of Sensation.—Sensation may be (1) in- creased (hyperesthesia); (2) lost (anaesthesia) or (3) perverted in various ways (paresthesia). Hypercesthesia may be due to (1) in- creased irritability of the sensory nerve fibres; (2) increased irri- tability of the sensory centres. Anaesthesia may be due to the same general causes which would lead to motor paralysis, the sensory centres and tracts being involved in cases of anaesthesia instead of the motor. Furthermore, there may be loss of the sense of pain (analgesia) without loss of tactile sense. Paresthesia may assume a number of forms, such as tingling, numbness, formication, feelings of constriction, sensations of heat and cold, &c. Disturbances of the Reflexes.—Both cutaneous and tendon nflexes may be (1) increased; (2) diminished or lost. The conditions which increase the reflexes are— 1. Cutaneous hyperaesthesia. 2. Excessive irritability of the nerve centers. 3. Increased irritability of the muscles. 4. Paralysis of or separation from the inhibitory centers. (Sets- chenow's center). PRACTICE OF MEDICINE. 239 The pathological conditions which cause a prolonged or perma- nent diminution or loss of some of the reflexes are— 1. Functional inactivity of sensory nerve terminals. 2. Functional inactivity of sensory nerve fibres. 3. Functional inactivity of reflex centers. 4. Functional inactivity of motor nerves in the cord. 5. Atrophy of multipolar cells in the anterior horns of gray matter. 6. Functional inactivity of motor nerve fibres. 7. Muscular atrophy. Temporary diminution or loss of reflexes may be due to irrita- tion of a sensory nerve or to shock. Disturbances of Nutrition (Trophic lesions)—Trophic lesions may result from affections of (1) the brain; (2) the spinal cord, in- cluding the medulla oblongata ; (3) the nerves. Secondary Degenerations.—Lesions of the large cells in the motor centers ofthe cerebral cortex or in the fibres leading downwards into the cord from these cells will cause atrophy and degeneration in the motor tracts of the cord below the seat of lesion, but the nerves themselves which pass out from the spinal cord will not be affected, nor will the muscles. There is an increase of connective tissue in the motor tracts of the cord after the atrophy and degene- ration of the nerve fibres. These changes in the cord are due to the separation of the motor tracts from the cells in the motor cen- ters, and are called "Secondary degenerations!' Lesions of the spinal cord may cause nutritive disturbances of the muscles, nerves, bones, joints, connective tissue and skin. Muscular Atrophy.—Trophic disturbances of the muscles and probably also of motor nerves are always due to lesions of the large multipolar cells in the anterior cornua or of the fibres leading there- from (as in acute anterior poliomyelitis and progressive muscular atrophy). Trophic Affections of the Bones, Joints, Skin, &c.—Nutritive disturbances of bones and joints (such as those which occur in loco- motor ataxia) and of the skin (such as acute decubitus and "glossy skin") are apparently connected in some way with those nerves and centers which are concerned with sensation. The ganglia on the posterior roots ofthe spinal nerves are frequently found diseased in cases of zona. Lesions of the peripheral nerves will occasion nutritive disturb- ances like those produced by spinal lesions. Irritative lesions of nerves cause much more severe trophic dis- turbances than section of a nerve would cause. 240 PRACTICE OF MEDICINE. Disturbances of the Electrical Reactions of Nerves and Muscles. The normal reactions are— [. With weak currents = KiSz — KaO — AnS — An(). 2. With moderate currents = KaSZ — KaO — AnSz — AnOz. 3. With very strong currents = KaS le—KaOz — AnSZ — AnOZ. (Ka = Cathode; An — Anode; S = Closing; O = Opening ; z = slight contraction ; Z — strong contraction; Te — Tetanic contraction.) The changes due to disease may be (1) quantitative (increase or diminution), and (2) qualitative. The changes which occur in the electrical reactions of nerves and muscles which have been separated from their trophic centers and are undergoing degeneration, constitute the "Reaction of De- generation," and are as follows : 1. If a faradaic or galvanic current is passed through a nerve which is undergoing degeneration in consequence of either separa- tion from its trophic center or inflammation ofthe nerve itself, there will be either no response at all or a very feeble one. 2. If a faradaic current be passed through a muscle which is undergoing degeneration there will be no response, or a feeble one, but— 3. If a galvanic current be passed through such a muscle the response will be increased, actually or relatively, and will show the following changes in character— (1) the muscular contractions will be slow, wormlike and per- sistent, and (2) the contractions at the anode will be as marked as those at the kathode, the formula being— Ka SZ — Ka O — AN SZ — An OZ. Diagnostic Value of the Reaction of Degeneration.—This reaction always shows that the lesion is in the large multipolar cells of the anterior cornua or in the peripheral nerves. Time of Appearance of the Reaction of Degeneration.— The reaction of degeneration appears in three or four days in cases of irritative lesions of nerves or trophic centers and in about a week or ten days in cases of section of a nerve. Duration of the Reaction of Degeneration and the Ultimate Result.—The reaction of degeneration usually lasts eight or ten weeks and may terminate either in recovery of normal reaction or in complete loss of all response. PRACTICE OF MEDICINE. 241 Simple and Multiple Neuritis. Definition and Frequency.—A comparatively rare disease, characterized anatomically by more or less inflammation and de- generation of the nerves and muscles and clinically by pain and paresis in the region of distribution of the affected nerves and by diminution or loss of reflexes, trophic disturbances and the reaction of degeneration. Causes.—1. Sex and age. Women who have passed middle life are most liable to have'multiple neuritis 2. Injuries of a nerve may cause a simple neuritis. 3. Exposure to cold, as in facial paralysis and sciatica. 4. Certain poisons, such as alcohol (which stands preeminent as a cause of multiple neuritis), lead, arsenic and mercury. Gout and rheumatism probably act by the retention of morbid matters in the blood in these diseases. 5. Certain infectious diseases, such as kakke (or beri-beri), diph- theria, anaesthetic leprosy and typhoid fever. Morbid Anatomy.—1. Extent. One or many neives may be involved. In the simple form, due to injury, a single nerve is usually affected. In multiple neuritis many nerves are implicated, especially the musculo-spinal and the anterior tibial. The corresponding nerves on the two sides are usually affected. 2. Changes in the nerves. There may be simply inflammation with scous exudate in the nerve sheath, or the interstitial connec- tive tissue and even the nerve fibres may be involved. In old, standing cases the connective tissue is increased and the nerve fibres undergo Wallerian degeneration. 3. The muscles also undergo degenerative changes, the striations disappearing and the fibres becoming small and granular. 4. Sometimes the skin undergoes an atrophic change and be- comes smooth and shining ("glossy skin"). Symptoms.— 1. Sensory. Pain and tenderness along the nerve and at its distribution during the early stages of the disease from the increased blood supply to the nerves ; various forms of par ces- thcsia occur also, such as numbness, tingling. &c. At a later stage anesthesia occurs from destructive changes in the nerve fibre. 2 Motor. In the early stages motion is little affected, except in severe cases, but when the disease is interstitial and the nerve fibres degenerate there is paresis or, possibly, complete paralysis. Ataxia is sometimes a marked symptom. 3 Reflexes. In the very early stages the reflexes are increased from the increased blood supply, but later they are impaired in all cases, from loss of conducting power in the degenerated nerves and consequent interruption of the reflex circuit. 31 24- PRACTICE OF MEDICINE. 4. Trophic. Atrophy and degeneration of muscles, herpes, oedema and glossy skin are of common occurrence. 5. Electrical reactions. The reaction of degeneration or the partial reaction of degeneration is present in nearly all cases. In the primary forms of multiple neuritis, due to alcohol or to infectious diseases, the 6. Onset is sudden, as a rule, and 7. The temperature is elevated—1020 to 1040. Diagnosis.— 1. From anterior poliomyelitis by the absence of sensory disturbances in the latter. 2. From loco-motor ataxia by the absence of eye symptoms, the rapid onset and the presence of the reaction of degeneration in multiple neuritis. Course and Prognosis.—The course is usually slow, but in some cases of multiple neuritis there may be a rapidly fatal course; the prognosis, ho .\ ever, is usually favorable. Treatment. — 1. To relieve pain by rest, phenacetine, the salicyl compounds and morphia. No form of electricity is advisable in acute cases. Hot applications may cause blisters or even sloughing 2. In the late stages to promote absorption and stimulate nutri- tion by iodide of potassium, arsenic, cod liver oil, strychnia, gal- vanism (and possibly faradism) and massage. F"acial Paralysis of Peripheral Origin. Definition and Frequency.—A common form of paralysis in- volving the muscles of one side of the face and due to disease or injury of the facial nerve on the distal side of its nucleus. Causes.— 1. Cold and exposure to draughts, which probably cause neuritis. 2. Caries of petrous portion ofthe temporal bone, the inflamma- tion in this cas: extending to tlu nerve and causing neuritis. 3 Pressure on the nerve by tumors at the base of the skull or by pieces of bone in fracture of the base of the skull or, rarely, by tumors of the parotid gland. 4. Injuries which directly involve the facial nerve. PRACTICE OF MEDICINE. 243 Symptoms.—The symptoms vary according to the degree of degeneration of the nerve. 1. The onset may be gradual, but the paralysis often occurs in a single night. 2. Sensory disturbances are entirely absent. 3. Motor. There is a paralysis ofthe orbicularis ofthe eye and all the muscles on one side of the face ; the eye on that side re- mains open, the mouth is drawn to the opposite side and the nor- mal furrows in the cheek are lost on the paralyzed side. Mastication is difficult, because the buccinator is paralyzed, and the food accu- mulates in the cheeks. 4. Reflexes and Electrical Reactions. The reflexes are impaired or lost and the reaction of degeneration is present in all but very mild cases. Diagnosis.—The diagnosis is very easy. The muscles which are paralyzed show that the facial nerve is involved and the reaction of degeneration shows that the disease is either peripheral or in the facial nucleus, but if the facial nucleus is involved (as in labio- glosso-laryngeal paralysis) there is more marked atrophy and the paralysis is not limited to the facial nerve. Course, Duration and Prognosis.—The course of facial paral- ysis is usually slow ; rarely recoverv occurs in two or three weeks, but usually it lasts several months and occasionally it is permanent. There is no danger to life. If the electrical reactions remain normal it shows thai only the nerve sheath is involved and recovery will probably occur at a comparatively early period. Treatment.— 1. To remove the cause, such as syphilis, inflam- mation ofthe ear, &c. 2. After the acute stage has passed, to stimulate the nerves and muscles by electricity (especially galvanism) and massage. Strych- nia is of service in old standing cases. All Peripheral Paralyses are similar with respect to their Causes, Morbid Anatomy, Course and Prognosis and Treatment. The Symptoms and Diagnosis are easily understood from a con- sideration of the distribution and function ofthe different nerves. Neuralgia. Definition and Frequency.—A very frequent affection, charac- terized by violent pain, paroxysmal in character, usually sudden in 244 PRACTICE OF MEDICINE. occurrence and not due to any morbid anatomical change in the nerves or other tissues. Causes.—A. Predisposing.— i. Age. The disease is rare in early childhood, and is most common in young adults. 2. Sex. As a rule, women are rather more liable to most forms Of neuralgia than men are; sciatic neuralgia, however, is more common in men. 3. A neuropathic tendency. 4. Irripaired nutrition, especially anaemia. B. Exciting. 1. Cold is a very common cause, especially of facial neuralgia. 2. Mechanical irritation, as by a decayed tooth, the pressure of a tumor or of hardened fceces on the nerves in the pelvis, &c. 3. Malaria, which is also a predisposing cause by interfering with nutrition, often seems to be a direct exciting cause, the paroxysms of pain occurring at definite periods. 4. Certain morbid matters in the blood, such as lead, zinc, urinae- mic solids, sugar, &c. 5. Irritations reflected from more or less distant parts, as in the case of sciatica, caused by stricture ofthe urethra, &c. Morbid Anatomy.—In neuralgia proper there is no morbid anatomical change, but many cases of so-called neuralgia are really neuritis (q. v.). Symptoms.— 1. Sensory. Pain is the essential symptom of neuralgia; it is usually limited to the area of distribution of a cer- tain nerve or nerves, is sudden in occurrence (usually), is parox- ysmal in character, and is apt to disappear from one place and appear in another. After it has persisted some time tender points appear in the course of the nerve. 2. Motor and reflex. There is no actual disturbance of motor power, but movement may cause pain and the reflexes are increased because of the increased irritability of the sensory centers and nerves. 3. Vaso-motor. Dilatation of the blood vessels in the painful region occurs, which is probably to be explained by Heidenhain's law that "irritation of a sensory nerve causes dilatation of the ves- sels in the area to which it is distributed and contraction of the vessels elsewhere." 4. Secretory. There is usually increased secretion if the neu- ralgia involves a mucous membrane or gland, due, probably, to the increased blood supply. 5. Trophic. Various disturbances of nutrition have been described in connection with neuralgia, especially when the eye is involved, but a neuritis is probably present in all cases when trophic lesions occur. PRACTICE OF MEDICINE; 245 6. Psychical. Insanity is an occasional Complication or sequel of that form of facial neuralgia known as " convulsive tic." Diagnosis.—The diagnosis of neuralgia is based on— i. Its sudden occurrence. 2. Its paroxysmal character. 3. Its tendency to jump from place to place. 4. The absence of trophic lesions and of the reaction of degen- eration. Prognosis. —The prognosis as to life is always favorable. Its duration and recurrence depend on— 1. Age—the prognosis being more favorable in early life. 2. The cause. Recovery being prompt and recurrence unlikely if the cause can be removed. 3. The form of the disease. Some cases of facial neuralgia in eldeily persons beiug extremely rebellious. Treatment.— 1. To remove the cause, such as anaemia, gout, rheumatism, diabetes, malaria, stricture ofthe urethra, &c. 2. To relieve pain by phenacetine, acetanilide, opiates, bella- donna, croton-chloral, quinine, gelsemium, aconite, arsenic, elec- tricity, chloroform liniment, chloral-camphor, blisters, &c. 3. To improve the general health by iron, arsenic, cod liver oil, strychnine, massage, and nutritious food. 4. Surgical measures— (1) Nerve stretching has been tried in sciatica, facial neuralgia and inter-costal neuralgia with variable success; it is only advisa- ble when medical treatment has failed, and if it gives relief, it is usually temporary. (2) Nerve section has been used, especially in facial neuralgia ; temporary relief nearly always follows, but it is rarely permanent. Trifacial Neuralgia. (Trigeminal neuralgia, facial neuralgia, tic douloureux.) Definition.—Neuralgia, involving one or more branches of the fifth pair of cranial nerves; it is the most common form or seat of neuralgia. Causes.—1. Those of neuralgia in general, with the addi- tion of— 2. Certain affections of the ear—otitis media. 3. Certain affections of the eyes, especially errors of refraction. 246 PRACTICE OF MEDICINE. Symptoms.—Sensory. Pain, usually very severe, which may involve the whole side of the face and part of the head, or may be limited to one or more branches of the nerves—supra-orbital, infra orbital and inferior maxillary. Tenderness also occurs at the points where these branches be- come superficial. 2. Motor and reflex. Reflex spasm of the facial muscles some- times occurs from the excessive irritability of the sensory centres and nerves. 3. The secretory and vaso-motor and trophic have already been mentioned in connection with neuralgia in general. Diagnosis.—The diagnosis from disease of the antrum and from abscess at the root of a tooth is made by the absence of great tenderness and the intermittent character of the pain. Course, Duration and Prognosis.—The course and duration vary. As a rule, the attacks are of short duration in young per- sons, but in elderly persons in feeble health tic douloureux is often exceedingly intractable. Treatment.—The treatment is that of neuralgia in general, but gelsemium is especially useful in facial neuralgia. Sciatica. Definition.—An affection characterized by pain in the region of distribution of the sciatic nerve, and in some cases by extreme tenderness ofthe nerve itself. In most cases the affection is a neu- ritis and not a simple neuralgia. Causes.— 1. Age and sex. The disease is most common in young adult or middle life. 2. Pressure on the nerve by uncomfortable seats, or by tu- mors, &c. 3. Stricture of the urethra—causing a reflex sciatica. 4. Diabetes, gout and rheumatism are also causes. Symptoms.—1. Sensory. Pain in the region supplied by the sciatic nerve and tenderness in the course of the nerve itself, the tenderness when present being due to neuritis. Paraesthesia in some form is common. 2. Motor. In many cases (where there is neuritis) there is more or less paresis ofthe muscles ofthe leg. practice of medicine. 247 3. In severe cases where the affection is ncuritic in character the reflexes are impaired, trophic disturbances such as oedema and even muscular atrophy occur, and the reaction of degeneration is present. Diagnosis.—True neuralgia is distinguished from neuritis af- fecting the sciatic nerve by the more paroxysmal character of the pain, the absence of marked tenderness, and of all evidences of de- generative change in cases of simple neuralgia. Prognosis and Duration.—The prognosis is favorable, but the disease often lasts for months, and relapses are frequent. Treatment.—The treatment is that of neuralgia in general. If the case be one of neuritis great care should be exercised in the use of hot applications for fear of causing severe blisters or even sloughing from defective trophic influence. (Gowers.) Salol and phenacetine give great relief in many cases. Inter-Costal Neuralgia. Definition and Frequency.—A very frequent affection charac- terized by neuralgic pain in the inter-costal nerves. > Causes.—This form of neuralgia is most common in young zvomen who are anemic, and especially if uterine disease be present, Symptoms.— 1. Sensory. Pain in the region of distribution of one or more inter-costal nerves is the essential symptom. There are tender points near the vertebral column, in the axillary line and in front where branches of the nerves become superficial. 2. Motor, reflex, trophic and electrical disturbances are only present in cases of neuritis. Diagnosis.—1. From neuralgia it is distinguished by the tender points and more paroxysmal character of the pain in inter-costal neuralgia. 2. From pleurisy by the absence of pleuritic friction sounds and of fever. Prognosis.—The prognosis is uniformly favorable. Treatment,—The treatment is that of neuralgia in general, 248 PRACTICE of medicine. DISEASES OF THE SPINAL CORD. Acute Spinal Meningitis. Definition.—An acute inflammation of the membranes sur- rounding the spinal cord, the pia mater being chiefly involved Causes.— 1. Age and sex. The disease occurs most frequently in young men; the reason is not known. 2. Exposure to intense heat or cold is a frequent cause. 3. Injuries, such as the puncture of a spina bifida or injuries to the spine. 4. Certain acute infectious diseases, such as typhoid fever, pneu- monia, &c. 5. Extension from neighboring parts, as in vertebral caries. 6. Tuberculosis, and possibly syphilis ; tuberculosis is a frequent cause, but the cerebral meninges are usually involved at the same time. Morbid Anatomy. — 1. Scat and extent. The pia mater is chiefly affected, and over a considerable extent, because the loose tissue offers no obstacle to the spread ofthe inflammation. 2. Condition of the vessels. The blood vessels are engorged with blood. 3. Changes in the membranes. The membranes are reddened, cloudy from albuminoid degeneration of their lining cells, and thickened from the exudate. 4. Nature of the exudate. The exudate is serous, sero-purulent or almost purely purulent, but usually contains flakes of fibrin. 5. Changes in the cord and nerve roots. The cord in severe cases is more or less inflamed and infiltrated with serum and white blood cells; the nerve roots are also inflamed ; the inflammation may be confined to the sheath, or the nerve fibres themselves may be in- volved. Symptoms.—The symptoms in the early stages are those of irritation; in the later stages, those of depression. 1. Sensory. Hyperesthesia of the skin and pain on movement are present in the early stages, and are due to the hyperexcitability of the inflamed nerves and nerve centres ; later there may be anaes- thesia from pressure of the exudate or degeneration of the nerve fibres. 2. Motor and reflexes. Spasms in the muscles supplied by the nerves coming from the inflamed area is observed, and the reflexes are increased in the early stages from the increased irritability of the nerves and nerve centres. Later there may be more or less paresis and weakening of reflexes from pressure on the cord and nerve roots by the exudate, or from degeneration of the nerve fibres. PRACTICE OF MEDICINE. 249 If the upper part of the cord (cervical) is involved, spasm of res piratory muscles occurs, causing dyspnea. 3. The temperature is elevated—1020 to 1040. Diagnosis.— I. From myelitis by the absence of spasms and the more marked paralysis of motion and sensation in myelitis. 2. From tetanus by the absence of "lock jaw" and the greater elevation of temperature in spinal meningitis. 3. From rheumatism by the absence of fever, as a rule, in mus- cular rheumatism, and the absence also of hyperaesthesia and dis- tinct spasm. Prognosis.—The prognosis is usually unfavorable; it is less grave in epidemic cerebro-spinal meningitis than in the form now under consideration. Complications and Sequelae.—Myelitis is a frequent complica- tion in severe cases, and in case of recovery, which is rare, sclerosis ofthe cord may occur as a sequel. Treatment.— I. To relieve pain by phenacetine, opiates, bro mide, chloral, &c. 2. To relieve congestion by cupping, ice bags, warm baths, pur- gatives, &c. Chronic Spinal Meningitis is a rare affection; it may follow the acute or may be chronic from the beginning. The exudate in such cases is fibrinous and productive, and ex- tensive adhesions and thickenings occur. The treatment consists in the administration of iodide of potas- sium, mercury and tonics, and the use of electricity, massage and counter-irritation. Classification of Diseases of the Cord. The following classification of diseases of the spinal marrow is commonly employed: 1. Focal lesions, in which the disease is confined primarily to a limited part of the long axis of the cord; such lesions usually in- volve the whole thickness of the cord, and are consequently often called transverse lesions. Such lesions, however, usually lead secondarily to degenerative changes in the efferent or motor tracts (crossed pyramidal tracts especially) belozv the seat of lesion and to similar changes in the afferent or sensory tracts (posterior median column, cerebellar tract and antero-lateral ascending tract) above the seat of lesion. 2. Systemic lesions in which certain definite and distinct systems of fibres or cells are involved throughout a great part or the whole 33 250 PRACTICE OF MEDICINE. length of the cord, the other portions of the cord being healthy. For example, in spastic spinal paralysis the crossed pyramidal tracts are alone involved, and in infantile paralysis the large multi- polar cells in the anterior cornua are exclusively affected. General Sympiomatouh;y of Tkansverse Lesions of the Spinal Cord. i. Paralysis of all the muscles belozv the seat of lesion, because the cords conveying motor impulses from the brain are divided. 2. Loss of sensation belozv the seat of lesion, because the sensory tracts are divided. 3. Increased reflexes and muscular rigidity belozv the scat of le- sion because the inhibitory tracts are divided. Loss of reflexes opposite the seat of lesion, because the refl.x cir- cuit is broken. 4. Trophic relations and electric reactions normal belozv the seat of lesion in muscles, because the trophic centres in the cord are not injured below the lesion. Degenerative changes and reaction of degeneration opposite the seat of lesion, because the trophic centres there are destroyed. 5. Functions of the bladder and rectum impaired, because the sensory tracts are divided and the patient is no longer conscious of the necessity for emptying these organs. Acute and Chronic Myelitis. Definition.—An acute or chronic inflammation ofthe spinal marrow nearly always transverse and limited in extent. Causes.—Often unknown. 1. Exposure to cold. 2. Exhaustion. 3. Sexual excesses. 4. Syphilis. 5. Acute infectious diseases. 6. Extension from the meningis. The way in which these causes act is not known except with respect to the last, which is self-evident. The influence of sexual excesses is very doubtful. practice of Medicine. 251 Morbid Anatomy.—1. Extent. As a rule, the whole of the cord transversely is involved, but the disease extends only a short distance upwards and downwards except along the sensory and motor tracts respectively. 2. Consistence. In the early stages the cord is softened at the inflamed spot from the serous exudate. In the late stages it is hard- ened because the white cells have become converted into connect- ive tissue. 3. Color. The color is redder than natural, and the outline be- tween the white and gray matter is lost. 4. Structural changes. The nerve fibres undergo the changes studied under Neuritis, q. v., and there is an infiltration with serum and white blood corpuscles in the early stages; later on, if the pa- tient lives, there is a great increase in connective tissue at the in- flamed spot, and a corresponding atrophy of nerve fibres. • Symptoms.—The symptoms depend on the seat of the lesion. 1. Motor. There is paraplegia below the seat of lesion, which is preceded for a short time by cramps in some cases, from the irri- tability of the nerves and nerve centres in the cord during the first stage. Fibril'ar twitchings occur, which cannot be explained satis- factorily. 2. Sensory. Slight and transient hyperaesthesia at first, from the congestion of the nerves and centres in the cord; later anes- thesia below the seat of lesion; opposite the seat of lesion a " gir- dle pain," probably due to the congestion at the upper limit of the inflamed spot. 3 Reflexes and Trophic (see General Symptomatology). 4. Urinary and rectal. These symptoms depend on the seat of lesion; if it is above the lumbar enlargement there is retention of urine and foeces (see Symptomatology) but if the lumbar cord and the vesical and rectal centres are involved there is paralysis of the sphincter with incontinence. (Incontinence of urine may occur from overfilling of the bladder also.) 5. Temperature. If the cervical cord is affected primarily or by extension there is a marked elevation of temperature, often to 1090 or no0. 6. Respiratory. If the cervical cord be involved there is dysp- nea from paralysis of the muscles of respiration. Diagnosis. — 1. From spinal meningitis. (See Meningitis). 2. From hysterical paraplegia by the absence of trophic lesions or reaetion of degeneration at any part in hysterical paraplegia and by the history of previous hysterical attacks. Course and Prognosis.—Myelitis usually runs an acute and fata! course, but more or less chronic cases sometimes occur. Oc- casionally, especially after injuries to the cord (from fracture ofthe spine, &c.j an ascending myelitis results. 252 PRACTICE OF MEDtCtNE. Complications;—1. Bed sores are of common occurrence, from pressure and defective cleanliness. 2. Cystitis and pyelo-nephritis, from retention of urine or the use of a septic catheter. Causes of Death.—1. Asphyxia, from paralysis ofthe respira- tory muscles. 2. Prostration from bed sores, &c. 3. Pyelo-nephritis, leading to urinaemic poisoning. Treatment.— 1. To remove the cause, such as syphilis, by mercury and iodide of potassium. 2. To lessen congestion by warm baths, ergot (?), position, &c. 3. To prevent cystitis by using a clean catheter. 4. To prevent bed sores by cleanliness and the use of a water- bed and to treat them when formed by iodoform and Peruvian bal- sam, &c. 5. To relieve other complications, such as cystitis, constipa- tion, &c. 6. To stimulate nutrition of the cord, after the acute stage, by galvanism, strychnine, arsenic and other tonics. Disseminated Sclerosis. (Insular sclerosis. Sclerosis in patches.) Definition and Frequency.—A rather rare disease, charac- terized anatomically by the formation of patches of connective tis- sue in different parts of the brain or cord, and clinically by various nervous symptoms, of which intention tremor, scanning speech and nystagmus are the most prominent. Causes.—Very little is understood as to the causes. Men between twenty and forty are usually affected. Heredity, exposure, overzvork and syphilis are possible causes. Morbid Anatomy.— 1. The extent is variable; the size of the patches varies from that of a pea to that of a small hickory nut; the most common seat is in the gray matter of the cord or the white matter of the cerebrum ; the lateral ventricles and pons are frequently affected. 2. The membranes over the spots are thickened. 3. Structural changes. The spots consist of connective tissue, cells and degenerated nerve fibres. Symptoms.—The symptoms depend on the seat. l. The onset is usually gradual. , Ji cases ieptift ! I St" '■;# ^ricter if! PRACTICE OF MEDICINE. 253 2. Motor. Tremor at every attempt to move is present in nearly all cases; if the motor tracts are involved paralysis may occur. Epileptiform attacks are common. 3. Sensory symptoms are absent as a rule. 4. Speech. The speech is slow, deliberate and "scanning" in character. 5. Ocular. Nystagmus is present in nearly all cases. 6. Mental. Patients with this disease are very emotional. Apo- plectiform attacks, with loss of consciousness, occur in the later stages. No explanation of the tremor, character ofthe speech and nys- tagmus has been found. Diagnosis. — I. From paralysis agitans, by the constant tremor in the latter. 2 From locomotor ataxia by the greater excursion ofthe move- ments in the latter disease and by the condition of the reflexes. Prognosis and Duration.—The prognosis is bad and the dura- tion usually many years. Treatment has been useless thus far—nerve tonics, galvanism nitrate of silver, chloride of sodium and gold, and other agents, have been tried without success. Locomotor Ataxia. Definition, Synonyms and Frequency.—A disease of the spinal marrow, characterized anatomically by sclerosis of the pos- terior columns of the cord and clinically by lightning pains, loss of certain reflexes and loss of coordinating power of the muscles. It is one of the most frequent of the spinal affections. Causes.—I. Age and sex. Men between twenty and fifty are most liable to the disease; it is rare in childhood and rarely begins after fifty. 2. Depressing conditions, such as overwork, sexual excesses, &c, are said to be causes. 3. Heredity (or the hereditary neuropathic tendency) is said to be a cause. 4. Syphilis is a cause in a large percentage of cases. Morbid Anatomy. — i. The spinal meninges over the posterior columns are thickened and opaque. 2. The posterior columns of the cord, especially the columns of 254 t'RACTICE OF MEDICINE. Gall are sclerosed: there is a great increase of connective tissue with corresponding destruction of nerve fibres. 3. The posterior nerre roots are more or less degenerated. Symptoms. — 1. Sensory. Lightning pains in the legs usually occur very early, numbness (in the feet especially), delayed sensation. and attacks of gastric pain ("gastric crises"). Generative, vesical ani rectal. Loss of sexual power, difficulty in emptying the bladder and constipation result from interference wiih the reflexes. 3. Ocular. Argyll-Robertson's pupil (see Reflexes) atrophy of the optic nerve and sometimes paralysis of certain muscles of the eye occur early. 4. Reflexes. Absence of patella tendon reflex and failure of the pupil to respond to light, though it changes for near and far vision, occur early and are of diagnostic import. 5. Motor. No loss of motor power, but loss of coordinating power, especially in the lower limbs. 6. Trophic. Inflammatory affections of the joints occur in a con- siderable proportion of the cases at a later stage, and in a few cases multiple fractures of bones have been observed (Charcot.) Diagnosis.— 1. From cerebellar disease by the absence of sen- sory symptoms and the giddiness in the latter affection. 2. From chorea by the occurrence of bizarre movements in chorea when no attempt at voluntary movement is made. 3. From general paresis by the absence of cerebral symptoms. 4. From multiple neuritis by the absence of the reaction of de- generation. Course and Prognosis.—The course of locomotor ataxia is very slow, the disease often lasting for years, but recovery is practi- cally unknown Treatment.—A. Hygienic. The avoidance of fatigue and of cold is important. B. Remedial. No principles of treatment can be laid down in this disease. Me cury and the iodides have not given the results which were expected from them; nor have nitrate of silver, zinc and chloride of sodium and gold, phosphorus, cod-liver oil and galvanism. Nerve stretching (of the sciatic) has seemed to ameliorate the symptoms. Suspension relieves the lightning pains in many cases, but does not exert a curative influence. In all stages of the disease phenacetine, acetanilide or antipy- rine are useful to allay the lightning pains or gastric crisis. PRACTICE OF MEDICINE. 255 Spastic Spinal Paralysis. (Spasmodic Tabes Dorsalis). Definition and Frequency.—A chronic disease of rare occur- rence, characterized anatomically by sclerosis of the lateral columns of the spinal cord and clinically by gradually progressive paresis and great increase of reflexes Causes.—The causes are unknown. The disease is most com- mon in young men and has been attributed to overwork and expos- ure to cold. Syphilis is a probable cause in a few cases. Morbid Anatomy.—The spinal cord only is affected ; there is a sclerosis of the crossed pyramidal tracts in the lateral columns of the cord on both sides. The nerve fibres atrophy and disappear and there is a great increase of connective tissue. Symptoms.—1. The onset is gradual and the course progressive. 2. Motor. There is a gradually increasing paresis on both sides —the legs being primarily and often exclusively involved; the pare- sis is due to a gradual destruction of the motor-conducting cords in the pyramidal tracts. 3. Reflexes. The reflexes are greatly increased, so that any attempt to move brings on a spasm of the muscles of the leg ; the increase of the reflexes is due to the destruction of the inhibitory- conducting fibres in the lateral columns. 4. Sensory, trophic and electrical disturbances are never present in uncomplicated cases. Diagnosis. — 1. From loco-motor ataxia by the great increase of reflexes and the absence of sensory disturbances. 2. From anterior poliomyelitis by the absence of muscular atro- phy and the increase of the reflexes. 3. From amyotrophic lateral sclerosis by the occurrence of mus- cular atrophy in the latter disease. 4. From multiple sclerosis by the absence of intention tremor. If patches of sclerosis involve both lateral columns, however, the symptoms of spastic spinal paralysis will be present (Charcot). Course, Duration and Prognosis.—The course ofthe disease is usually progressive, the duration, months or years, and the danger to life very slight. Treatment.—Galvanism, nerve tonics and nerve stretching have been tried without benefit. Massage and prolonged warm baths have seemed to lessen the spasm. Strychnine is always injurious, 256 PRACTICE OF MEDICINE. Amyotrophic Lateral Sclerosis. Definition and Frequency.—A rare disease ofthe spinal cord, chronic in course and characterized anatomically by sclerosis of the crossed pyramidal tracts and atrophy of the large multipolar cells in the anterior cornua of gray matter. Causes.—The causes are unknown ; the disease is most com- mon in young men. Morbid Anatomy—i. Cord. The pyramidal tracts are sclerosed —the nerve fibres being degenerated and atrophied and the connec- tive tissue greatly increased and the large multipolar cells in the anterior cornua are atrophied. The upper part of the cord is affected first. At a late stage the nuclei of the hypoglossus and vagus ac- cessory become involved. 2. Muscles. The muscles correspo 'ding with the diseased part of the cord are degenerated and atrophied. Symptoms.—i. Motor. There is a gradual loss of motor power from two causes—first, because the conducting cords in the pyra- midal tracts are gradually destroyed, and secondly, because of the degeneration ofthe muscles themselves. 2. Trophic. The motor nerve fibres connected with the atrophied cells in the anterior cornua and the muscles which they supply are degenerated because their trophic cells are destroyed. The paresis and atrophy begin in the muscles ofthe hand and arm, the legs are subsequently affected and still later the muscles of speech and deg- lutition, because the nuclei in the medulla undergo degeneration. 3. Reflexes. The reflexes are increased in spite of the degenera- tion of the multipolar cells, because some of the reflex circuits remain and inhibitory impulses from Setschenow's center are cut off by the sclerosis of the pyramidal tracts. 4. Electrical. In the degenerated muscles there is complete or partial reaction of degeneration. 5. Sensory disturbances are absent. Diagnosis.—1. From spastic spinal paralysis by the absence of any muscular degeneration in the latter. 2. From progressive muscular atrophy by the absence of spastic symptoms in this disease. Course, Duration and Prognosis.—The course is progressive, the duration long, the prognosis, as to recovery, hopeless. Treatment.—The treatment is purely symptomatic and is ut- terly ineffectual. PRACTICE OF MEDICINE. 257 Chronic Bulbar Paralysis. (Glosso-labio-laryngeal paralysis.) Definition.—A chronic disease of comparative rarity, charac- terized anatomically by atrophy of certain nuclei in the medulla oblongata, and clinically by gradually progressing paresis and atrophy of the muscles of the tongue, lips, pharynx and larynx. Causes.—The causes are unknown ; the disease is more com- mon in men after 35 years of age. Morbid Anatomy. — 1. Medulla oblongata. There is degenera- tion and atrophy of the nuclei of the hppoglossus, vagus, accessory, facial and glosso-pharyngeal nerves. 2. The nerves leading from them are degenerated and also the muscles which they supply, namely—the tongue, the muscles of the lips, pharynx and larynx. Symptoms.— 1. The onset is very gradual; (rarely there is an acute form of bulbar paralysis.) 2. Motor and trophic. There is gradual loss of motor power and simultaneous degeneration and atrophy of the tongue and lips leading to difficulty in speech, of the pharynx, leading to difficulty in szvallozving and consequent emaciation, and of the larynx, leading to respiratory disturbances and to secondary bronchitis and pneu- monia from the entrance of foreign bodies into the air passages. 3. The reflexes (throat reflex especially) are lost or greatly di- minished from the break in the circuit (atrophy of cells, nerves and muscles). Occasionally reflexes are increased from simultaneous atrophy of the inhibitory fibres above the nuclei in the medulla. 4. The pulse is sometimes very rapid from involvement of the vagus center. 5. Sensory symptoms are absent. Diagnosis.—The diagnosis is based on the paresis or paralysis and muscular atrophy in the region supplied by the bulbar nerves. Course, Duration and Prognosis.—The course is progressive, the duration from two to five years, the prognosis hopeless. Causes of Death.—The causes of death are— 1. Exhaustion from inability to swallow. 2. Asphyxia from laryngeal paralysis. 3. Cardiac failure from involvement of the vagus. 4. Complications, such as in inhalation pneumonia. Treatment is without avail. Galvanism, nitrate of silver, ergot and many other remedies have been tried; none haye been found of much, if any, service. 33 258 PRACTICE OF MEDICINE. Acute Anterior Poliomyelitis. (Infantile Paralysis.) Definition and Frequency.—A disease of comparatively com- mon occurrence in children, rare in adults, acute in course, charac- terized anatomically by degeneration of the large multipolar cells in the anterior cornua of gray matter of the cord, of the nerves passing out from these cells and the muscles which these nerves supply, and characterized clinically by muscular atrophy and paraly- sis of certain muscles or groups of muscles. Causes. — i. Age The disease is far more common in children between the ages of one and four years than at any other age. 2. Season. It occurs chiefly in hot weather, and is probably due to chilling when overheated in some cases (Gowers). 3. There are many symptoms which suggest that the disease is infectious in character. Morbid Anatomy.— 1. Cord. There is degeneration and at- rophy of the large cells in the anterior cornua and an increase of the connective tissue at the same point. 2. Nerves and muscles. The nerves passing from these cells to the muscles, and the muscles themselves are degenerated. 3. The bones often fail to keep pace in growth with other parts of the body and the joints are loose and flabby, probably in great part from the loss of muscular support. Symptoms.—1. Onset. The onset is sudden. 2. Temperature. The temperature in the early stage is elevated (1030—105°) and this may continue several days. 3. Nervous and muscular. Convulsions, unconsciousness or delirium are frequent in the early stages. Later the characteristic symptoms appear, which are— 4. Motor and trophic. There is paralysis in one or more limbs, with wasting of the muscles from atrophy of the trophic cells in the anterior cornua. 5. Reflexes. The reflexes are lost, because the circuit is broken. 6 Electrical. There is reaction of degeneration, because of de- generative change in the muscles and nerves. 7. Sensory. There is no sensory disturbance, because the dis- ease is confined to motor and trophic cells and nerves. Diagnosis.—The disease is often confounded with Neuritis (Gowers) from which it may be distinguished by the absence of sensory disturbances in poliomyelitis. Prognosis. — The prognosis as to life is good in the great ma jority ot cases, and in nearly all cases there is great diminution also in the extent of paralysis in the course of a few weeks, but atrophy of the muscles of one limb is usually permanent. Complete re- covery may occur, but is rare. Practice of medicine. 259 Treatment.—A. In the early stage the bromides and phenace- tine or acetanilide to reduce fever and nervous irritability. B. At a later stage galvanism to stimulate regeneration of the nerves, strychnine and possibly ergot (?) for the same purpose, and mechanical appliances to correct the resulting deformities (talipes, &c.) Progressive Muscular Atrophy. Definition and Frequency.—A rather rare disease, very grad- ual in its onset, chronic in its course and characterizd by atrophy of the large cells in the anterior cornua and of certain muscles, with consequent paralysis. Causes>—The causes are very obscure. i. Age and sex. Young adults are more liable to it than per- sons at other periods of life and men more than women. 2. Excessive work of certain muscles (?) 3. Heredity and consanguineous marriages (f) Morbid Anatomy.—1. Cord. The large cells in the anterior cornua are degenerated and the connective tissue around them is increased. There is no other morbid change in the spinal cord. 2. The anterior nerve roots and motor nerves and the muscles are also degenerated. Symptoms.—1. The onset is exceedingly gradual. 2. Motor and trophic. Atrophy and paralysis of certain mus- cles; the thenar and hypo-thenar eminences are nearly always involved first, then the other muscles of the hand, of the arm and of the trunk ; the thigh and leg muscles are involved last. 3. The reflexes are diminished or lost because of the changes in the motor nerves and nerve cells. 4. The reaction of degeneration or the partial reaction of degen- eration is present. Sensory symptoms are absent. Diagnosis.— 1. From neuritis by the absence of sensory dis- turbances. 2. From amyotrophic lateral sclerosis by the absence of spasm. 3. From acute anterior poliomyelitis by the gradual onset and absence of fever. Prognosis and Duration.—The disease is chronic in course, of long duration, often fifteen or twenty years, but is hopeless as to recovery. Treatment is of no avail. 260 PRACTICE OF MEDICINE. PSEUDO-HYPERTROPHIC PARALYSIS. (Primary Muscular Atrophy.) Definition and Frequency.—A rare disease, characterized by atrophy and paralysis of some of the muscles without any affection of the cord. Causes. — I. Age and sex. Boys between eight and twelve years old are usually affected. 2. Heredity. Several members of the same family may be suf- ferers with the disease. 3. Neuropathic tendency. Morbid Anatomy.—1. Muscles. The muscles of the back and thighs are usually involved. The fibres are small, but not de- generated nor granular, nor do they lose their stricture. In some cases there is an apparent hypertrophy of the muscles from an in- terstitial deposit of fat. 2. There is no change in the nervous system. Symptoms.—1. Motor. Gradual loss of motor power in the muscles of the back and thighs and later in other muscles. 2. The reflexes are diminished because of the loss of muscular tissue (simple atrophy). 3. No reaction of degeneration, because no degeneration occurs. 4. The trophic lesions consist in simple atrophy of muscles and usually an increase in connective tissue and insterstitial fat. Diagnosis.—From progressive muscular atrophy by the different muscles involved, the age of the patient and the absence of reac- tion of degeneration. Prognosis.—The prognosis is unfavorable ; the course is slow. Treatment.—Electricity and massage are said to have caused some temporary improvement, or, at least, to have checked, for a time the progress of the disease. No other agents have produced any effect. Acute Ascending Paralysis. (Landry's Paralysis.) Definition and Frequency.—A rare disease, characterized by a rapidly developing paralysis, commencing in the lower limbs and extending upwards, with elevation of temperature and splenic enlargement. PRACTICE OF MEDICINE. 26l Causes and Morbid Anatomy.—The causes and morbid anato- my are unknown. It is probable that in some cases the disease is a multiple neuritis and in others an acute ascending spinal paralysis. In many respects the affiction resembles the acute infectious diseases. Symptoms. — i. Motor. Paralysis usually commencing in one lower limb, involving the other in a short time and rapidly extend- ing upwards. 2. Sensory. The sensory symptoms are variable, often there are none ; sometimes there is anaesthesia. 2. Reflexes usually lost. 3. Electrical reactions variable. 5. Fever—(1020 or 1030)—and slight splenic enlargement in all cases. Diagnosis.—The diagnosis is based on the course and charac- ter of the symptoms. Prognosis and Duration.—Duration a few weeks. Many cases end in recovery. Treatment.—Symptomatic in early stages. Electricity and massage later. DISEASES OF THE BRAIN. Cerebral Hyperemia. Definition and Varieties.—An excess of blood in the brain which may be—1. Active, when an excess of arterial blood reaches the brain, and 2. Passive, when there is some obstacle to the return of venous blood from the brain. Causes.—A. Of the active form—1. Alcohol, which causes increased action of the heart and dilatation of the vessels. 2. Certain drugs, as amyl nitrite, &c, which cause dilatation of the cerebral vessels. 3. Over exertion, which increases the force and frequency ofthe heart's action. B. Of the passive form—Any obstruction to the venous circula- tion, such as occurs in the later stages of cardiac disease, and from pressure of tumors in the neck, and, also, any serious interference with respiration, such as occurs in croup. 262 practice of medicine. Morbid Anatomy.—The morbid anatomy is not striking—some dilatation of the vessels, with increased redness of the brain and membranes, and in the passive form some serous effusion is all that is fcund. Symptoms.—A. In the active form increased mental activity, sleeplessness, hyperesthesia, &c, from increased cerebral activity. B. In the passive for n, depression of all the cerebral functions, drowsiness, stupor, &c. Diagnosis.—The diagnosis is difficult; it is based on the char- acter of the symptoms, the causes and the absence of any evidence of organic disease. Prognosis.—The prognosis depends upon the cause; it is usually good in the active form and serious in the passive. Treatment.—To reduce the amount of blood in the brain— 1. In the active form by bromides, cold to the head, intestinal derivation, counter irritants, &c. 2. In the passive form by digitalis, ergot, &c. Cerebral Anaemia. Definition and Varieties.—A diminution of the amount of blood in the brain; it may be—1. General, or 2. Local. The general form only will be described here. Causes.—1. General anemia. 2. Certain cardiac diseases, such as aortic obstruction and failing compensation in any form of heart disease. 3. Reflex from disturbances of the stomach or other organs. 4. Cerebral, as mental shocks. Morbid Anatomy.—More or less pallor of the brain and its membranes. Symptoms.—In acute cases (an ordinary fainting fit), giddiness, nausea, pallor, loss of consciousness and loss of motor power and sensation; such an attack usually lasts only a few moments. In chronic cases, want of decision of character, irritability of temper, pallor and the other symptoms of the causative condition. practice of medicine. 263 Diagnosis.—The diagnosis is based on the symptoms and history of the case and presents no difficulty. Prognosis.—The prognosis of an ordinary fainting fit is nearly al- ways good. The prognosis of the chronic form of cerebral anaemia depends on the cause: in cases of general anaemia it is usually good, in car- diac diseases unfavorable. Treatment.—1. Of a fainting fit—to increase the amount of blood in the brain by the horizontal position, amyl nitrite, alcoholic stimulants and ammonia. 2. Of the chronic form—to remove the cause, it possible, by iron, strychnine and, in most cases, by the use of digitalis (in failing compensation). Cerebral Meningitis. Denifition and Divisions.—Cerebral meningitis is an inflamma- tion ofthe membranes surrounding the brain. 1. Pachymeningitis is an inflammation of the outer membrane or dura mater. Either the external or internal surface of the dura may be involved, constituting external pachymeningitis and internal pachymeningitis, respectively. External pachymeningitis belongs in the domain of surgery. 2. Simple acute meningitis or leptomeningitis is the form of men- ingitis which occurs sometimes in connection with injuries, ear diseases, pneumonia, &c. 3. Tubercular meningitis or basilar meningitis (sp called because the base of the brain is chiefly involved) is due to the bacillus tuberculosis. Internal Pachymeningitis. (Haematoma of the dura mater). Definition.—A disease characterized by the formation of con- nective tissue with repeated extravasations of blood on the internal surface of the dura.. 264 PRACTICE OF MEDICINE. Causes.— 1. Age and sex. The disease is most common in old men. 2. Intemperance. 3. Chronic, renal and cardiac disease. 4. Syphilis. It is not clear how these causes act, but probably in part at least by causing a degenerative change in the walls of the blood vessels. Morbid Anatomy—On the internal surface ofthe dura, usually in the parietal region, there is a new formation of very vascular connective tissue with extravasations of blood of various dates. Symptoms.— 1. The onset is usually sudden and relapses arc frequent. 2. Mental. Stupor and coma immediately after the attacks and mental weakening in the intervals, probably due to pressure. 3. Motor. Sometimes convulsive attacks, from irritation, may occur, but usually there is monoplegia or paresis. 4. Sensory disturbances are absent, as a rule. Diagnosis.—The diagnosis is based on the repeated occurrence of the attacks, with mental weakness. Prognosis.—The prognosis is uniformly unfavorable, but life may be prolonged for some time. Treatment—The avoidance of stimulants, over exertion and excitement in order to prevent hemorrhage. The use of iodide of potassium and mercury has been recom- mended, but has not been followed by any appreciable results. Simple Acute Meningitis. (Leptomeningitis.) Definition.—An inflammation of the cerebral pia mater. Causes. —1. Injuries, such as fractures of the skull, &c. 2. Diseases of the ear, leading to inflammation of the petrous portion ofthe temporal bone or of the mastoid cells, which, by ex- tension, leads to meningitis. 3. Certain acute infectious diseases, especially pneumonia and erysipelas. PRACTICE OF MEDICINE. 265 Morbid Anatomy—1# The pia mater loses its transparency and becomes cloudy from albuminoid degeneration of its cells and serous infiltration ; it is, of course, greatly reddened, and the injected vessels can be seen coursing through the thickened and opaque membrane. 2. The brain is injected, and if the exudate is considerable the convolutions are flattened and softened by the serous exudate. 3. The exudate is considerable in quantity, is most abundant along the fissures and large vessels, and is sero-purulent in character. Symptoms.—The symptoms are first, those of irritation, and later, those of depression. 1. Sensory—headache, intolerance of light, hyperaesthesia from the increased irritability of the nerves and nerve centers in the early stages. 2. Mental. Delirium in the early stages, followed by stupor and coma from pressure of the exudate. 3. Motor and reflexes. Spasm of certain muscles, especially those of the eye, in the early stages, wi^h contraction of the pupil, from increased reflex irritability, followed by paralysis from pres- sure on the nerves or nerve centers by the exudate and dilated and immovable pupils, from pressure on the motor oculi nerve and loss of reflex. 4. The pulse is at first full and slow from irritation ofthe brain; later, it becomes rapid and irregular. 5. The temperature is elevated—1000 to 1020—as a rule, but it may be higher, especially just before death. 6. Digestive. Vomiting is common, and is probably due to the irritation of the 4th ventricle. Constipation is the rule. Diagnosis.—I. From typhoid fever by the different temperature curve, the absence of eruption and the presence of paralysis of some of the ocular muscles. 2. From pneumonia by the absence of the physical signs of the latter disease. 3. From uremia by the absence of albuminuria. Prognosis and Duration.—The prognosis is almost uniformly fatal and the duration only a few days. Treatment. — I. To lessen the amount of blood in the train by bromides, purgatives and cold to the head. 2. To relieve pain by morphia'and the bromides, m 266 PRACTICE OF MEDICINE. Tubercular Meningitis. (Basilar Meningitis ; acute hydrocephalus.) Definition and Frequency.—An inflammation of the pia mater, especially marked at the base of the brain, and due to the bacillus tuberculosis. Causes. — I. The bacillus tuberculosis. 2. Secondary to tubercular disease elsewhere, as in the lungs or glands especially. 3. Age. It is far more common in children than in adults. Morbid Anatomy.—1. Seat. The usual seat is at the base of the brain. There are tuberc'es on the membranes, especially marked along the blood vessels, and also the changes of leptomeningitis (q. v.). 3. The exudate is chiefly serous in character, but it contains a number of cells and some fibrinous flakes. Symptoms.—A. Prodromic. Listlessness, headache and slight fever for a week or two, prior to the development ofthe attack, are common. B. Of the developed attack. The symptoms are much the same as those already mentioned under simple meningitis, but spasm and subsequent paralysis of the ocular muscles is more marked because the base of the brain is chiefly affected and the nerves are involved where they emerge from the brain. Convulsions are very prominent in children, probably because the inhibitory centers are not well developed in early life. The temperature is usually higher than in simple meningitis. Vomiting is a very common symptom, especially in the early stages ; it is projectile in character. The abdomen is "boat shaped," from contraction of the abdomi- nal muscles. Emaciation is rapid and prostration great. Diagnosis.—The diagnosis is based on (1) the history of the case; (2) the age of the patient, and (3) the presence of tubercles elsewhere. Prognosis.—The prognosis is unfavorable; it is doubtful whether recovery ever occurs. Treatment.—The prophylactic treatment is that of tuberculo- sis, in general (q. v.). The remedial treatment consists in the administration of the bromides, chloral, &c, to control the convulsions, and in the relief of other symptoms as they arise. Iodide of potassium is thought by some to be beneficial. practice of medicine. 26/ Chronic Hydrocephalus. Definition.—An accumulation of fluid within the cranium, usually in the ventricles of the brain. Causes.— i. Age. The disease is often congenital or occurs in the early months of life. 2. Family tendency. Several children in the same family are frequently affected. Morbid Anatomy.—i. The size of the head is greatly in- creased. 2. The skull bones are very thin and the sutures and fontanelles widely open. 3. The fluid is very thin, contains a little chloride of sodium and is contained chiefly in the lateral ventricles. Symptoms.—i. Appearance. The head is large and round; the eyes turned down so as to show the sclerotic. 2. Nervous. The mental powers are weak, and muscular power impaired. General. The body and limbs are, as a rule, small and shriv- elled. Diagnosis.—The diagnosis is very simple. Prognosis.—The prognosis is bad, and hydrocephalic children rarely live to be more than five or six years old. Treatment.—No medical treatment has given any results. Aspiration of a small quantity of fluid and strapping may be tried. Topographical Diagnosis in Brain Diseases. Only a brief outline of cerebral localization will be given here, and only those affections will be considered which most frequently present themselves to the practitioner. Direct and Indirect Focal Lesions — i. A direct focal lesion is one which causes a destruction of the nerve cells or fibres, and is more or less permanent. 2. An indirect focal lesion is one which causes a temporary dis- turbance of certain nerve centers or conducting cords from pressure or temporary interference with the blood supply. The symptoms produced by a direct focal lesion are more or less permanent; those produced by an indirect focal lesion are usu- ally temporary. 268 PRACTICE of medicine. Localization of Brain Diseases. SYMPTOMS. I. Hemiplegia, with facial paralysis and loss of consciousness, but with general improvement, and, possibly recovery. 2. Same symptoms, but with late rigidity on paralyzed side. 3. Hemi anesthesia, with loss of con- sciousness. 4. Motor aphasia. 5. Word deafness. 6. Facial monoplegia or monospasm. 7. Brachial monoplegia or mono- spasm. 8. Monoplegia or mono spasm involv- ing the muscles of the leg. 9. Crossed facial paralysis. io. Crossed ocular pnr.alysis. 11. Inco-ordination, with increased ten- don reflex and giddiness. 12. Lateral homonymous hemi-anopsia. 13. " Soul blindness." 14. Difficulty of articulation or of swal- lowing. SKAT OF LESION. Direct focal lesion near motor tracts, probably in motor ganglia; indirect local lesion of motor tracts—probably internal capsule. [. Cortical motor centers, or 2. Corona radiata, or 3. Anterior %d of internal capsule. Posterior third of internal capsule. Posterior part of third left frontal convo- lution. Posterior part of first left temporal con- volution. Lower part of ascending frontal and parietal convolutions. Middle part of ascending frontal and parietal convolutions. Upper part of ascending frontal and pa- rietal convolutions and para central lobule. Lower half of pons Varolii. Cerebral peduncle. Cerebellum. Occipital convolutions, (especially the cuneus) 01 the fibres between them and the optic chiasm. Angular gyrus on the left side. Medulla oblongata. Irritative and Destructive Lesions.—Irritative lesions of the cortex cause spasm. Destructive lesions ofthe cortex cause paralysis. Epileptiform attacks with a visual aura are due to irritative dis- turbance in the occipital lobes. Epileptiform attacks with an aural aura are due to an irritative disturbance in the first temporo-sphenoidal convolution. It should be remembered, of course, that cerebral spasm and paralysis are on the opposite side of the body from the seat of lesion. In the case of crossed facial and crossed ocular paralysis, the face PRACTICE OF MEblCINE. 269 or ocular muscles, as the case may be, are paralyzed on the side of lesion, while the limbs are paralyzed on the opposite side. Cerebral Tumors. Varieties.— 1. Glioma. 2. Sarcoma. 3. Gumma. 4. Tubercle. 5. Cancer. Causes.—I. Age and Sex. Brain tumors, with the exception of tubercle, are most common in middle life and in the male sex. 2. No cause can be assigned for any except syphilis and tubercle. Symptoms.—A. General. 1. Sensory. Headache is almost invariably present, and is usually persistent and severe. Hyper- esthesia over a part of the cranium is occasionally present. Headache is due to intra-cranial pressure. 2. Mental. Emotional disturbance, hysterical in character, and mental weakness, are common. 3. Motor symptoms depend upon the seat. 4. Circulatory. The pulse is usually slow, from increased intra- cranial pressure. 5. Digestive. Vomiting is a common symptom. It is projectile in character and cerebral in origin. 6. Ocular. Choked disk is present in nearly all cases from in- creased intra-cranial pressure, and is of diagnostic importance. 7. General. Loss of flesh and strength are common, but not invariable symptoms. They are most marked in cases of cancer and tuberculosis. B. Focal symptoms are both direct and indirect, and vary with the seat of the tumor and the amount of pressure it exerts on sur- rounding parts. (See Topographical Diagnosis in Brain Diseases). Diagnosis.— 1. From abscess by the much more gradual onset, the presence of choked disk and the absence of fever, as a rule, in the case of brain tumors. 2. From apoplexy and thrombosis by the gradual onset. 3. From hysteria by the choked disk. Course, Duration and Prognosis.—The course is progressive, the prognosis bad, the duration from a few months to several years. Recovery is possible if the tumor be syphilitic. 270 PRACTICE OF MEDICINE. Treatment.— I. To remove the cause by antisyphilitic treat- ment if there is a suspicion of syphilis. 2. To relieve pain and cerebral congestion by the bromides, phe- nacetine, &c.; opium is not advisable, because it increases the amount of blood in the brain. 3. Surgical treatment is advisable in all cases when the tumor can be definitely located, is probably circumscribed and can be reached without great risk. The removal of tumors, in cases of spasm, due to irritation of the cortex, and also in cases of epilepsy, &c, has often given favorable results. Cerebral Hemorrhage. (Apoplexy.) Causes.—A. Predisposing. 1. Disease of the walls ofthe vessels, such as miliary aneurisms, atheroma and syphilis. 2. Alcoholism, syphilis, gout and Bright"s disease, which cause impairment of the walls of the blood vessels. 3. Age and sex. Men in advanced age are more liable to apo- plexy than others, because the vascular walls are degenerated in advanced age. B. Exciting. 1. Violent exertion. 2. Mental excitement. 3. Cardiac Stimulants. 4. Immoderate eating. All these causes act by increasing the force of the heart's beat and the pressure in the vessels. Morbid Anatomy.—1. Seat. Any part ofthe brain may be involved, but the most usual seat of hemorrhage is in the central ganglia and internal capsule, because the vessels^there are subjected to excessive pressure. 2. Size. The size varies from that of a small nut to a mass two or three inches in diameter. 3. Appearance of the clot. At first, the clot is dark and soft; later, it becomes firmer, and may either be absorbed, leaving a scar, or it may form a sack containing fluid and surrounded by a wall of connective tissue. 4. Condition of surrounding brain tissue. At first, the surround- ing brain tissue is ragged and infiltrated with serum and some blood corpuscles; later, it returns in part to its normal condition, and a wall of connective tissue is formed around the remains of the clot. PRACTICE OF MEDICINE. 271 5. Descending sclerosis. If the motor centres or motor tracts are destroyed there is a descending degeneration of the pyramidal tracts in the cord. Symptoms.—The symptoms depend on the seat and size of the clot. 1. The onset is nearly always sudden, but severe headache, numbness, &c, may precede the attack. 2. Mental. Loss of consciousness occurs in most cases, but not in all; it is due partly to pressure and partly to anaemia of the cor- tex. Mental weakness occasionally occurs at a late stage. 3. Motor. Paralysis—nearly always hemiplegia—with involv- ment of the face is the most striking symptom. Rigidity of the muscles of the limbs on the paralyzed side occurs after a time, and is due to the cutting off of inhibitory influences from the brain. Conjugated deviation of the eyes—the balls being turned up- wards and outwards—" looking towards the lesion " is frequent in the early stages. In right hemiplegia aphasia usually occurs. 4. Sensory. Hemi-anaesthesia occurs occasionally, and is due to the involvment ofthe posterior third ofthe internal capsule. 5. Circulatory. At first the pulse is feeble from shock, later it becomes full and slow, and still later weak and irregular if a fatal termination is approaching. 6. Temperature. The temoeratwre falls at first, from disturbance ofthe heat centres; later it rise1;, probably from inflammatory dis- turbance around the clot 7. Respiratory The respirations are full and slow, often irreg- ular, and stertorous in character, from paralysis of the muscles of the soft palate and cheek. 8. Reflexes. The reflexes are at first lessened or abolished, from shock, but later the tendon reflexes are increased in the paralyzed side because inhibitory influences are cut off". 9. Trophic. " Acute decubitus" (bed sores) occurs early on the buttock of the paralyzed side. Diagnosis. — I. From uremia by the absence of albuminuria. 2. From thrombosis and embolism with great difficulty by the absence of the causes of thrombosis and embolism and by the age ofthe patient—apoplexy usually occurring at a later period of life than thrombosis and embolism. Course and Prognosis.—An attack of apoplexy does not usually terminate fatally at once. Improvement in motor power usually occurs, and if the lesion ofthe motor tracts be indirect recovery may occur. Aphasia may. be entirely recovered from in the early years of life especially, the right side of the brain taking on the function of articulate speech. Rigidity of the limbs on the paralyzed side occurs usually if the motorand inhibitory tracts are destroyed. " Post-hemiplegic chorea " occurs in some cases. 272 PRACTICE OF MEDICINE. Mental zoeakness may result, but is not frequent except in very advanced life. Recurrence is probable. Complications.—1. Bed sores. 2. Inhalation pneumonia. Treatment—1. To reduce blood pressure by absolute rest, amyl nitrite, bleeding, &c. 2. To drazv blood from the head by cold to the head, purgatives, the bromides, &c. In late stages— 3. Galvanism (a weak current) to the head—of doubtful value —and faradism and massage to the limbs to prevent contraction of the muscles. Thrombosis and Embolism of the Cerebral Vessels. Definition and Causes.—(See General Pathology.) Morbid Anatomy.— 1. Usual seat. The left middle cerebral artery is the usual seat, but other vessels may be plugged. 2. Changes in the brain substance. The blood supply to the area of distribution of the plugged vessel is cut off, and softening occurs because the vessel is a terminal one. The color of the soft- ened spot may be either white, red, or yellow. It is zvhite in the early stage from coagulation necrosis, or it may be tinged red by blood, and later it becomes ycllozv from fatty degeneration. The softened spot contains white blood corpuscles, large corpuscles con- taining fatty matter, broken up nerve cells and fibres, and granular matter. Symptoms.—The symptoms differ but little from those of cere- bral hemorrhage. The onset is often rather more gra !ual. but this is practically the only difference and not always observable. Diagnosis.—The diagnosis from cerebral hemorrhage is often impossible, but is based on the following points : 1. The presence of cardiac disease which would cause em- bolism. 2. The age of the patient. Apoplexy occurs usually in ad- vanced life. 3. The more gradual onset (occasionally) of the symptoms of thrombosis. PRACTICE OF MEDICINE. 273 Prognosis.—The prognosis is usually unfavorable, but if the focal lesion does not involve directly the motor centres or tracts, recovery may occur. Aphasia is often more pronounced in embolism and thrombosis than in hemorrhage, but as the disease occurs chiefly in early life recovery from the aphasia is more apt to occur. Treatment---The treatment does not differ essentially from that of apoplexy, except that bleeding is never advisable in cases of thrombosis and embolism, and sustaining treatment is more often indicated. Carbonate of ammonia has been advised with a view of dis- solving the clot, but its value is exceedingly problematical. Acute Cerebral Paralysis of Children. (Acute Encephalitis of Children.) Definition and Frequency.—A rather rare affection, usually occurring between the ages ot one and four years, and character- ized by its sudden occurrence, febrile character and subsequent hemiplegia and rigidity. Causes.—None can be assigned. The affection is probably due to the same causes as acute anterior polio-myelitis. Morbid Anatomy.—The motor centres in the cerebrum and the fibres leading therefrom down into the motor tracts are degen- erated so as to cause degeneration of the pyramidal tracts. Symptoms.—The symptoms in the early stages are like those of poliomyelitis—the onset is sudden, and there is fever and usu- ally convulsions. When these cease hemiplegia is found to be present, and spastic symptoms (rigidity) occur later on. There is an arrest of development, but no reaction of degeneration, and the reflexes are increased. Diagnosis.—The diagnosis is very simple when rigidity de- velops. Prognosis.—The prognosis as to life is usually good; as to complete recovery it is bad. Treatment.—The treatment is purely symptomatic. 35 274 PRACTICE OF MEDICINE. General Paralysis of the Insane. (General Paralysis. General Paresis.) Definition and Frequency.—A comparatively common disease of the nervous system, characterized by mental weakness and va- rious motor disturbances. Causes. — I. Age and sex. The disease usually occurs in men between twenty and fifty. 2. Syphilis is by far the most common cause. 3. Mental ovcrzvork may be a predisposing cause. Morbid Anatomy.—1. Seat. The anterior part of the brain is chiefly involved, but any part may be affected. 2. Structural changes. The nerve cells and fibres undergo de- generative atrophy and there is an increase of connective tissue. 3. Cord. Sclerosis of the posterior columns is of common oc- currence, and sclerosis of the lateral columns may occur. Symptoms.—1. The onset is usually gradual. 2. Mental. A loss of mental balance is usually the first indica- tion ; loss of moral sense, "delusions of grandeur" and other forms of mental disturbance may be observed. 3. Speech. The speech is affected, words being frequently pro- nounced wrong and used in the wrong connection. 4. Ocular. Inequality of the pupils and loss of pupillary reflex are often observed. 5. Motor. Tremor of the lips when attempting to speak, ataxia of the limbs, sometimes spastic symptoms and rarely paralysis occur. 6. Reflexes. Usually the reflexes are lost (posterior sclerosis), but sometimes they are increased (lateral sclerosis). Diagnosis.—The diagnosis is based on the mental disturbances, combined with the physical symptoms mentioned. It differs from simple locomotor ataxia in the fact that in the latter there are no cerebral symptoms. Prognosis.—The prognosis is unfavorable; the duration may be several years or only a few months. Treatment.—The treatment consists in complete mental and bodily rest and the use of mercury and iodides. Confinement in an asylum is advisable in many cases. Practice of medicine. 275 FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM. Definition.—Functional diseases of the nervous system are those in which up to the present time no essential and character- istic morbid change has been found. With respect to epilepsy, however, (and perhaps some other diseases of this class) it should be remembered that epileptiform at- tacks may occur from certain well-marked lesions of the cortex of the brain, but these cases are not examples of true epilepsy. Epilepsy. Definition and Varieties.—A disease characterized, as a rule, by convulsive attacks and loss of consciousness. This is the usual form or variety. Other varieties are— " Petit malf in which there is no convulsion, but only a sudden and brief loss of consciousness. Brief attacks of insanity (Samt's Psychical Equivalents). Causes.—I. Age. The disease may occur at any age, but in the great majority of cases it begins before twenty. 2. Heredity. A neuropathic tendency, shown by some form or other of nervous disease in the ancestors or near relatives, is pres- ent in about one-third of the cases. 3. Injuries of the skull, meninges, brain substance and periph- eral nerves may occasion epilepsy, but when the brain or its membranes or the skull are involved, it is usually Jacksonian epi- lepsy and not a simple functional disease. 4. Emotional disturbances and possibly excessive mental work may induce attacks in persons who are predisposed to the affection. 5 Probably syphilis in some cases. Symptoms.—A. Prodromic. An aura is of common but by no means invariable occurrence; it may be (1) motor, (2) sensory, (3) secretory, (4) psychical. B. Durino- the attack. 1. Mental. There is loss of conscious- ness in the ordinary form, and this is followed by coma, and then by sound sleep as a general thing; sometimes by temporary in sanity which may last a few moments only or several hours. 276 PRACTICE of medicine. 2. Muscular. Convulsions, at first—for a few seconds—tonic in character and then clonic; the convulsions sometimes begin in one limb and then become general, or they may be general from the beginning. 3. Sensory. Sensation is temporarily abolished. 4. Circulatory. The circulation is interfered with by the mus- cular contraction and the pulse is consequently irregular and the face livid. 5. Respiratory. The respirations are irregular and stertorous and the patient froths at the mouth. Often there is a cry at the commencement, from sudden contraction of some of the muscles. 6. Excretory. The urine and faeces are often discharged invol- untarily. C. Symptoms of " le petit rual". In this form there is no con- vulsion, but a simple and brief loss of consciousness; occasionally there is some sensory disturbance at the same time. D. Immediately after the attack there is usually profound stupor, but there may be temporary insanity and occasionally aphasia. E. In the intervals betzveeu the attacks the patient is sometimes perfectly well, but in many cases there is a gradually progressive mental weakness ; in children there is arrest of mental development in many cases. F. The duration and frequency of the attacks vary. The usual duration of the convulsion is a few moments ; of the stupor an hour or two ; but the attacks occasionally come in rapid succession for several hours or days (" status epilepticus ") ; in other cases the interval between the attacks may be several days or even months or years. Diagnosis.—I. From hysteria by the more complete uncon- sciousness and the history of the case. 2. From urinemia by the absence of any considerable amount of albumin in the urine and the history of the case. Prognosis.—The prognosis as to life is usually good; but sud- den death occasionally occurs during or just after a convulsion. The prognosis as to complete recovery is not usually very good. Results.—If the disease develops in adult life and the attacks are infrequent there may be no serious mental impairment. In children there is usually arrest of mental development. Attacks of insanity may take the place of epileptic seizures or follow ordinary attacks. Treatment.— 1. To remore the cause, if possible, by antisyphi- litic treatment when necessary, by removing tumors or other irri- tants of the cortex. 2. To lessen nervous irritability and spasm, by the bromides, nitro-glycerine, amyl nitrite, belladonna, borax, antifebrine, sulfo- nal, &c. PRACTICE OF MEDICINE. 277 3. To improve the general health by cod liver oil, zinc, &c. The bromides are by far the best remedies in most cases. The acne which bromine causes may be relieved or prevented in many cases by naphthol or salicylate of bismuth, taken internally, or by arsenic. Surgical treatment. The removal of tumors, of depressed bone, of cicatrices, &c, is only advisable in Jacksonian epilepsy when the localizing symptoms are well marked. Infantile Convulsions. Convulsions frequently occur in children from reflex causes (im- proper food, teething (?), &c), or in connection with febrile distur- bances or the acute infectious diseases; they occur, also, as a rule, in the early stages of acute cerebral paralysis and acute anterior poliomyelitis and in rickets. They are attended by loss of consciousness and usually a greater or less elevation of temperature. The prognosis depends upon the cause. The treatment is addressed to the removal ofthe cause, by pur- gatives, &c, and to lessening nervous irritability, by chloral, the bromides, acetanilide, warm baths, &c. Hysteria. Definition and Frequency.—A very frequent affection, char- acterized by the most varied emotional, sensory and motor disturb- ances. Causes.— 1. Age and sex. The disease is most common in young women, but may occur at any age and in either sex. 2. Neuropathic diathesis. A tendency to nervous diseases in other members ofthe family is often found. 3. Emotional excitement is a very common exciting cause. 4. Anemia and debility are common predisposing causes. 5. Uterine disease was formerly thought to be intimately asso- ciated with hysteria, but the connection is now considered doubtful. 278 Practice of medicine. Symptoms.— i. Psychical. Instability is the chief characteristic of the psychical symptoms. The emotions are easily excited. 2. Motor. Spasm ofthe muscles of the throat (globus hysteri- cus) ofthe limbs and oi the trunk is very frequent. Paralysis is also of frequent occurrence. Both the spasm and paralysis are characterized by their want of permanence. 3. Sensory. Hyperesthesia and anesthesia are common symp- toms. Ovarian hyperaesthesia is especially frequent. Precardial pain is present in many cases, and is probably due to spasmodic contraction ofthe blood vessels. 4. Reflexes. The reflexes may be increased or diminished ; as a rule, they are increased. 5. Circulatory. The pulse is rapid and tense. 6. Urinary. At the close of an attack there is usually a flow of limpid urine from the increased blood pressure. Diagnosis.— 1. From epilepsy. (See epilepsy.) 2. From puerperal eclampsia by the absence of albuminuria. 3. From cerebral tumors by the absence of choked disk. 4. From paralysis from organic disease by the more transitory character ofthe symptoms. Prognosis and Duration.—The prognosis as to life is always good ; relapses are very frequent. The duration of an attack may be only a few moments, or it may last weeks or months. Most attacks are of short duration. Treatment.—1. To remove the cause, such as anaemia, excite- ment, &c. 2. To stimulate the zvill power by moral treatment. 3. To allay nervous irritability by valerian, Hoffmann's anodyne, assaicetida, musk, &c. 4. To improzic the general health by arsenic, strychnia, phos- phorus, quinine and other tonics. Catalepsy. Definition and Frequency.—A rather rare disease, nearly allied to hysteria, and chance ized by loss of consciousness and a peculiar condition of the muscles which causes the limbs to remain for some time in any position in which they may be placed. Causes.—The causes are the same as those of hysteria. Symptoms.—1. The onset is sudden and the attacks are parox- ysmal. practice of medicine. 279 2. Psychical. There is loss of consciousness and loss of sen- sation. 3. Motor. The limbs may be placed in the most singular positions and will remain so for some time. 4. The respirations are full and slow, and the pulse soft and compressible. Diagnosis.—It is distinguished from simulated catalepsy by the length of time that a limb—the arm for instance—will remain extended. Prognosis.—The prognosis is usually unfavorable. Treatment.—The treatment is the same as that of hysteria. An emetic will often stop a paroxysm of cata'epsy or hysteria at once. Chorea. Definition, Frequency and Synonym.—A common func- tional disturbance of the nervous system, characterized by involun- tary contractions of certain muscles or groups of muscles, the movements being of considerable extent—differing in this respect from tremor. It is often called St. Vitus's dance. Causes. — 1. Age and sex It is more common in children and young adults than in advanced life; zvomen or girls are more often affected than boys. 2. The neuropathic diathesis probably has some influence on its development. 3. Emotional excitement and overzvork are probable causes. 4. Rheumatism is by far the most prominent cause. Symptoms.—1. Psychical. Occasionally there is some mental weakness, which is temporary in duration. 2. Motor. A muscle or a group of muscles will contract and cause jerking movements. Different muscles are affected at differ- ent times and at short intervals. 3. Sensory disturbances are absent. Diagnosis.—I. From epilepsy by the fact that there is no loss of consciousness in chorea and the spasmodic movements are more limited in extent. 2. From disseminated sclerosis by the absence of intention tremor and the greater excursion of the movements in chorea. 280 practice of medicine. Duration and Prognosis.—The duration is variable; it may last a few weeks or several months. The prognosis is nearly always favorable, except in the case of pregnant women. Results.— Valvular disease of the heart is a frequent result. Treatment. — I. To allay nervous irritabiltiy by chloral, the bromides, acetamlide, phenacetine, &c. 2. To improve the general health by tonics, such as cod liver oil and iron, and especially arsenic. Paralysis Agitans. Definition and Frequency.—A rather rare affection, confined almost exclusively to persons of advanced age, and characterized by constant tremor. Causes.—i. Age and sex. The disease is rare before sixty and is rather more common in women than in men 2. Emotional disturbances increase, if they do not cause the trouble. Symptoms.—The symptoms are exclusively motor and consist in constant tremor of the hands and head and often of other parts. The altitude is striking—the patient bending forward and showing a tendency to rush forward on the slightest push from behind. Diagnosis. — From disseminated sclerosis by the absence of in- tention tremor. Duration and Prognosis.—When once developed, the disease persists through life, but the prognosis is favorable, so far as life itself is concerned. Treatment is useless. Writers' Cramp. Definition and Frequency.—A rather rare affection, charac- terized by cramp of the muscles used in writing when such work is attempted. PRACTICE OF MEDICINE. 28l Cause.—The only cause is overzvork of the muscles involved. Possibly the neuropathic diathesis has some influence on its produc- tion. Symptoms. — 1. Sensory. There is a feeling of weight and stiffness in the affected muscles. 2. Motor. The muscles used in writing undergo spasmodic contraction whenever such work is attempted. Diagnosis.— I. From lead palsy by the absence of any paraly- sis of the extensors of the hand and of other evidences of lead poisoning. 2. From insular sclerosis by the absence of tremor and the more marked spasm of the muscles. Duration and Prognosis.—The prognosis as to life is of course good, but is doubtful as to recovery, and the affection may last through life. Treatment.—1.— Absolute rest to the muscles involved is im- perative. Mechanical appliances to hold the fingers apart in writing are useful. 2. Galvanism and massage are sometimes beneficial. Sunstroke. (Insolation.) Causes.—1. Heat, especially moist heat, which prevents evapo- ration from the skin. 2. Auxiliary causes are exhaustion, stimulants and over-eating. Symptoms.—A. Prodromic symptoms, which do not always occur, are headache and dizziness. B. The symptoms of a developed attack may occur in three forms, which are usually combined— 1. Heat prostration, in which the skin is cool, the pulse feeble ble and consciousness is retained. 2 Sunstroke proper, in which the symptoms are much like those of heat prostration, except that there is loss of consciousness and shallow respiration. \ 3 Thermic fever, which is characterized by very high tempera- ture often 1090 or uo°, a full and slow pulse, later becoming rapid and feeble, and profound coma. 282 PRACTICE OF MEDICINE. Diagnosis.—The diagnosis is based on the history and usually presents no difficulty. Prognosis and Results.—About one half of the persons affected with sunstroke die. Heat prostration is the least and thermic fever the most danger- ous. Recovery from any form is slow, the patients being liable to severe headache for months afterwards, and occasionally insanity results. Treatment.— I. In heat prostration and sunstroke proper the most important point is to sustain strength by ammonia and brandy, the latter being administered with great caution. 2. In thermic fever, the reduction of temperature is of the fiist importance. The cold bath, applications of ice, and antipyrine hypodermically, are the best agents for this purpose. Neurasthenia. Definition.—A functional affection characterized by defective strength and tone of the nervous system. Causes.—I. Age and sex. The affection is most common in men in young adult or middle life. 2. Sexual excesses, excessive study, emotional excitement, and the excessive use of alcohol and tobacco are probable causes. 3. The neuropathic diathesis predisposes to neurasthenia. Symptoms.—1. Cerebral. A feeling of pressure about the head and inability to do prolonged mental work are the chief cerebral symptoms. 2. Motor. There is usually muscular weakness, and the patient is easily fatigued. 3. Sensory symptoms, other than headache and sometimes pain in the eyes, are not usually very marked. 4. Genital. Diminution or loss of sexual power is a common symptom. Diagnosis.—1. From organic disease of the cord by the ab- sence ot the symptoms of such disease. 2. From cerebral tumor by the absence of choked disk. Prognosis and Duration.—The prognosis as to life is good, Practice of medicine. 283 The duration very uncertain, and relapses are frequent. It does not lead to organic disease. Treatment.— 1. To remove the cause by mental rest, the avoid- ance of excitement and the removal of injurious influences. 2. To improve nutrition of the nervous system, by life in the open air, the administration of tonics, such as iron, strychnia, cod liver oil, phosphorus and arsenic and the use of galvanism and massage. Sick Headache. (Megrim. Migraine.) Causes.—1. Age and sex. Sick headache is rather more com- mon in women than in men, and occurs usually in youth and early adult life. 2. Heredity, or the occurrence of some form of nervous trouble in previous generations, can usually be determined. 3. Emotional excitement and digestive disturbances are frequent causes. 4. Anomalies of refraction frequently cause attacks of severe headache. Symptoms. — 1. Special senses. Disturbances of vision are very common at the beginning of an attack. 2. Sensory. The headache is usually intense and there is often a feeling of stiffness in the muscles. 3. Digestive. Nausea is a common, but by no means an inva- riable symptom. Vomiting may occur often just at the close of an attack. 4. Vaso-motor. As a rule, the face is pale, but in some cases there is flushing. 5. Urinary. Frequently at the close of an attack there is a profuse flow of limpid urine from the increased blood pressure during the attack. Diagnosis.—The diagnosis is easy and needs no comment. Frequency, Duration and Prognosis. The attack mayoccur everv few days or at intervals of weeks or months. The duration is usually several hours and often the termination is sudden. The prognosis as to life is good and the attacks usually become iess frequent with advancing years. 284 PRACTtCE OR MEDICINE. Treatment.—I. To remove the cause, when possible, by cor- recting errors of diet, avoiding excitement or overwork and the use of proper glasses when necessary. 2. To correct circulatory disturbances. In some cases where there was flushing of the face ergot has been found useful, and when pallor exists amyl-nitrite and nitro-glycerine are beneficial. 3. To lessen the pain, phenacetine, acetanilide, antipyrine, gua- rana, potassium bromide, codeia, &c, have been used. Few cases fail to yield to phenacetine, antipyrine or guarana. Sea-sickness. Sea-sickness may be caused by any unusual motion, and is char- acterized by great prostration and intense nausea. The prognosis is nearly always favorable, but in long voyages death may occur from exhaustion. The treatment consists in the administration of champagne and other stimulants, hydrocyanic acid, the bromides, amyl nitrite and nitro-glycerine. Exophthalmic Goitre. (Graves's Disease. Basedow's Disease.) Definition.—A disease characterized, when fully developed, by Swelling of the thyroid gland, protrusion of the eyeballs and rapid action of the heart. Causes.—1. Age and sex. The affection is far more common in women than in men, and occurs usually between the ages of twenty and forty. 2. The neuropathic diathesis is a predisposing cause. 3. Emotional excitement and menstrual disturbances increase, if they do not cause the affection. Symptoms.—1. Cardiac. The pulse is very rapid, often 130 to the minute, and is usually full and strong. Irregularity is not common. 2. Thyroid. The thyroid gland is enlarged, but not usually to a very great extent. PRACTICE OF MEblCtNE. 285 3. Ocular. The eyes protrude and when the patient looks down, in some cases, the upper lid does not follow the ball (von Grsefe's symptom.) Diagnosis.—The diagnosis is based on the simultaneous occur- rence ot rapid action of the heart, thyroid enlargement and protru- sion of the eyes. Prognosis and Duration.—The prognosis as to life is good. The duration is long and complete recovery rare. Treatment.—The treatment consists in the administration of digitalis and ergot and the use of galvanism applied to tht goitrous enlargement and the sympathetic nerves in the neck. Tetany. (Intermittent tetanus.) Definition and Frequency.—A very rare affection of the ner- vous system, characterized by intermittent spasms of certain groups of muscles. Causes.—The disease is more common in children and young adults and, especially, in nursing women. Cold is sometimes a cause. Symptoms.—The prodromic symptoms are slight pain and stiff- ness in the muscles. During the attack there is a tonic contraction of some of the mus- cles of both upper extremities, as a rule. There are no sensory dis- turbances, but the irritability of the muscles is greatly increased. and a slight blow upon them will cause contraction. The attacks vary greatly in frequency and duration. They are usually several days or weeks apart, but the paroxysms may occur every few moments. The attack (not the paroxysm) may last for several weeks. Prognosis.—The prognosis is usually favorable. Treatment.—The treatment consists in the use of an ascending galvanic current and the administration of bromides or other nerve sedatives. 286 Practice of medicine. Athetosis. Athetosis is a rare and peculiar affection of the nervous system, characterized by constant movement of certain muscles; those which move the fingers are most commonly involved, but the mus- cles of the lace and neck and also of the trunk and lower limbs may also be involved. The causes are unknown. The disease often occurs after hemi- plegia. The symptoms have already been mentioned under the definition. The movements are constant, except during sleep. The prognosis as to life is good ; as to recovery bad. No treatment has been found of any avail. PRACTICE OF MEDICINE. 287 APPENDIX. [The diseases treated of in this appendix were accidentally omit- ted from their proper position.] Measles. (Rubeola.) Definition and Frequency.—An acute, infectious and very contagious disease, characterized by coryza and the occurrence of a papular eruption. It is of great frequency. Varieties.— 1. Simple measles, in which the case runs a mild course. 2. Malignant or black measles, in which the eruption is very dark in color, from great congestion and the case runs a severe course. Causes.—1. A germ which has not been isolated. 2. Media of contagion, the atmosphere, clothing, letters, &c, the germs being contained in the mucous secretions, blood and epithelial scales. 3. Avenues of introduction, the respiratory passages and, possi- bly, the skin (by inoculation). It is infectious at all stages. 4. Immunity is conferred by one attack, as a rule. 5. Age. It may occur at any age, but children are more liable to it, probably because they are not protected by a previous attack. 6. The period of incubation is about ten days. Morbid Anatomy.— 1. Changes in the larynx and bronchi. The mucous membrane of the larynx and bronchi and also that of the nose is inflamed. 2. The conjunctive are also inflamed. 3. The changes in the skin will be described under symptoms. Symptoms.—A. Prodromic. 1. Coryza is a very prominent prodromic symptom ; bronchitis is also present and persists after the eruption comes out. 2. Temperature. The temperature is elevated, usually about 1020 to 1040. B. Eruptive stage. I. Characteristics of the eruption; it appears on the fourth day, is papular in character, appears first on the face, is usually bright red in color and each papule is about one-eighth of 288 PRACTICE OF MEDICINE. an inch in diameter; the rash reaches its height on the third day and disappears by the sixth. 2. The temperature is about 1040 or 1050 and falls quite sud- denly when the rash has been out about two days. 3. Respiratory. Cough persists during the eruptive stage. 4. Digestive. Nausea and vomiting are common symptoms and diarrhcea may occur as a comnlication. C. Desquamative stage. Desquamation occurs in the form of small scales and a severe cough (the " iron cough ") lasts for some time after the eruption has disappeared. Irregular Attacks.—Attacks of measles may occur without any or with but very slight eruption. Black measles is a severe type, in which the eruption is very ex- tensive and the congestion of the skin great. Diagnosis.— I. From scarlet fever by the premonitory coryza and the absence of sore throat and by the papular character of the rash. 2. From small pox by the coryza and the character ofthe erup- tion. Prognosis.—The prognosis is good in uncomplicated cases. It is dependent on (i) hygienic surroundings, over-crowding adding to the danger; (2) temperature, the higher the temperature the greater the danger; (3) the character of the rash; (4) age, it is more serious in adults than in children; (5) previous health, and (6) com- plications (q. v.) Complications.—1. Capillary bronchitis from extension of in- flammation to the smaller tubes. 2. Catarrhal pneumonia from extension, the inhalation of noxious products from the tubes and probably also from the presence of leucomaines. 3. Inflammation of serous membranes and nephritis are rare in measles, but sometimes occur from the action of leucomaines. 4. Affections of the eyes and ears. Conjunctivitis is common, and is often quite severe; otitis media is also common, and fre- quently a severe complication ; it results from the passage of germs up through the Eustachian tube. 5. Intestinal catarrrh from the elimination of leucomaines by the mucous membrane ofthe intestines. 6. Acute tuberculosis probably because the lungs are weakened and less able to resist the action of germs. Treatment.—A. Prophylactic. The only prophylactic is isola- tion. B. Medicinal. 1. To avoid chilling and prevent complications by confinement to bed and the avoidance of draughts. 2. To prevent injury to the eyes, by keeping the room dark and prohibiting reading. PRACTICE OF MEDICINE. 289 3. To reduce hyperpyrexia and relieve headache, by phenacetine and other drugs of its class. 4. To relieve bronchitis, by vapor inhalations and the administra- tion of ipecac, squills or similar expectorants, with opiates in small doses. German Measles. (Rotheln. Rubella.) Definition.—An acute infectious and moderately confagious disease, characterized by a rash, papular in character, but the pa- pules are smaller than those of measles. Causes.— 1. A germ probably, but it has not been isolated. 2. The medium of contagion is probably the atmosphere, but the disease is apparently not very contagious. 3. The avenue of introduction is probably the respiratory mucous membrane. 4. Children are more liable to the disease than adults. 5. Immunity is conferred by one attack. 6. The period of incubation^ is from ten days to three weeks. Morbid Anatomy.—There is no characteristic morbid anat- omy, but the glands at the back of the neck are nearly always enlarged. Symptoms.—The subjective symptoms are usually very slight. 1. The eruption is often the first symptom ; it is in small papules, red in color, and lasts about two days ; desquamation seldom, if ever, occurs. 2. The temperature is very little elevated. 3. The eyes are frequently inflamed, and are left weak when the attack is over. 4. The glands at the back of the neck are enlarged. Diagnosis. — I. From measles by the absence of coryza and the smaller size ofthe papules. 2. From scarlet fever by the absence of sore throat and the papular character of the eruption. Prognosis.—The prognosis is uniformly good. Treatment.—The treatment is purely symptomatic. Entire 7 290 PRACTICE OF MEDICINE. rest to the eyes is important. If headache is, severe, as occa.ionally happens, phenacetine may be used with advantage. Small-pox. (Variola.) Definition.—An acute infectious and very contagious dis- ease, characteiized by the occurrence on the skin and mucous membranes of an eruption, first macular, then papular, vesicular and pustular, the pustules being umbilicated. Varieties.—1. Discrete when tne pustules are scattered. 2. Confluent when the pustules run together, forming a more or less continuous mass of pustules or scabs. 3. Hemorrhagic in which the exudate is blood instead of pus ; this is the most severe form. Causes.— 1.—A germ, which has not been isolated. 2. The favorable condition for development is overcrowding, but the disease is highly contagious under all circumstances and at all stages. 3. The avenues of introduction are (1) an abraded surface; (2) the respiratory mucous membrane. 4. The media of contagion are the air, clothing, persons sick with the disease, &c 5. Immunity is nearly always conferred by one attack. 6. Age. It may occur at any age, even in intra-uterine life. 7. The period of incubation is from five to thirty days unless the disease is inoculated, when it is about forty-eight hours. Morbid Anatomy.—1. The internal organs are congested, the spleen being enlarged considerabl}, probably from the action of the leucomaines and also from the inability of the skin to do its proper work. 2. The skin shows an eruption at first macular and then suc- cessively papular, vesicular and pustular. The whole thickness of the skin is involved, as a rule; the individual spots are from i«th to % th of an inch in size, and the skin at the point infiltrated with se- rum and cells. In the vesicular stage the eruption becomes umbili- cated from the exudate around the circumference of the spots, the centre being held down by flattened epithelial cells. Each pu.stule PRACTICE OF MEDICINE. 29! is divided into several compartments by the framework of epithe- lial cells. 3. The mucous membrane undergoes changes similar to those in the skin. Symptoms. — i. Nervous. A chill, headache, very severe back- ache, delirium, restlessness and somnolence. All these symptoms are probably due to the poisoning by leucomaines and to the fever. 2. Temperature. The temperature is elevated at first—1020 to 1040—but usually falls on the fourth day, when the eruption ap- pears On the eighth or ninth day, when suppuration occurs in the pustules, there is another rise of temperature, often to 105° or even 1090, which is due to the absorption of septic matter. It de- clines gradually in favorable cases and usually disappears by the fourteenth or fifteenth day. 3. The circulatory symptoms are rapid pulse, which is due to the fever, and later, weakness of the heart's action, from albumi- noid degeneration and the prostration caused by weakness. 4. The digestive symptoms are nausea and vomiting and sore throat—the former due probably to the action of leucomaines and the swallowing of morbid matters, and the latter (sore throat) to the eruption in the throat. 5. Cutaneous. Sweating usually occurs in the early stages. The eruption begins on the face usually. It appears on the fourth day, and has the character already mentioned under morbid anatomy. The pustules dry and form crusts, which come off from the fourteenth to the eighteenth day and usually leave pits. Usually a macular eruption appears before the real rash of small pox, but it lasts only a short time. Diagnosis.—1. From measles by the violent backache, the ab- sence of marked coryza, and above all by the rash which soon be- comes vesicular and then pustular. 2. From typhus fever by the character ofthe eruption. In many cases it is impossible to make a diagnosis in the early stages before the vesicles and pustules appear. Complications.— 1. Pulmonary and laryngeal. Broncho-pneu- monia from the inhalation of morbid matter and ulceration and possibly stenosis of the larynx from the ulceration. 2. Special sense. Otitis media may occur from extension from the throat. Occasionally keratitis and ulceration ofthe eyes occurs. 3. Urinary. Albuminuria is common, and occasionally well- marked nephritis occurs. Prognosis.—The prognosis is always serious, and is influenced by the tollowing circumstances : 1. Amount of eruption and type of the disease; varioloid is least dangerous ; discrete small-pox is less dangerous than confluent, and hemorrhagic is most dangerous. 2. Intemperate habits increase the danger. 292 PRACTICE OF MEDICINE. 3. Previous good health renders the prognosis more favorable. 4. Pregnancy adds greatly to the danger. The time of greatest danger is the eighth day. Causes of Death.—-1. Toxemia, from the amount of leuco- maines absorbed. 2. Exhaustion, from extensive suppuration and poisoning. Treatment.—A. Prophylactic. 1. Vaccination (q. v.) 2. Quarantine. To be protective the quarantine must be thor- ough and all fomites must be destroyed or thoroughly disinfected. B. Medicinal. 1. To reduce temperature by phenacetine, &c. 2. To allay restlessness by the bromides, phenacetine, codeia and other analgesics. 3. To promote eruption when slow in appearing, by warm baths and Dover's powder. 4. To sustain strength by nutritious food, and stimulants if ex- haustion is imminent. 5. To prevent pitting by the application of a paste of carbolic acid, glycerine and prepared chalk. ( There is no satisfactory method of preventing pitting.) During desiccation warm baths with subsequent oiling of the surface should be employed to promote the removal of the crusts. Varioloid'is a mild form of small-pox which occurs usually in those who are partially protected by vaccination. In itself it is not dangerous, but it may cause severe small-pox in others who are unprotected. Vaccination. Varieties Of Virus.—1. Non-humanized, which is obtained di- rectly from the cow pox pustules on the udder, and 2. Humanized, which is obtained from a vaccination pustule or scab on the human being. Protective Power.—Persons properly vaccinated are almost entirely protected from the danger of small pox, but the immunity does not last indefinitely, so that vaccination should be repeated every three or four years. » PRACTICE OF MEDICINE. 293 Relative Advantages of Bovine and Humanized Virus.— Bovine^ virus causes a more severe sore, as a rule, than humanized, but it is more satisfactory in its results, and there is no danger of communicating other diseases when it is employed. Method of Procedure.—The skin should be slightly scratched or prkked, so as to get through the outer layers of the skin, but bleeding should be avoided because the blood may wash out the virus. Having scratched the skin, the virus is to be rubbed over the surface. If a " vaccine point" is used, the end of the point on which the virus is must be moistened with water first and then rubbed on the scratched or punctured surface. Changes at and Around the Vaccinated Spot.—For sev- eral days there is no inflammatory reaction; on the fourth or fifth day it commences to inflame, and a vesicle, and subsequently a pus- tule, is formed by the eighth or ninth day; the pustule is umbilica- ted, and dries into a crust which comes off on the fourteenth day. Circumstances which interfere with the success of vaccination are (i) erysipelas and (2) certain acute and chronic skin diseases. Some people are unsusceptible to it. Diseases Which may be Communicated by Vaccination.— Syphilis and possibly tuberculosis may be communicated by vaccina tion with humanized virus, but such accidents are extremely rare. Chicken-pox. (Varicella.) Chicken-pox is an eruptive disease which occurs usually in chil- dren. The eruption is in the form of pustules which are usually very few in number, and which lead to pitting. It is contagious and is much more common in children than in adults. The symptoms are seldom marked. There may be slight fever and malaise, and sometimes there is much itching of the surface around the pustules, which resemble those of small-pox, being usually umbilicated. The prognosis is always favorable, and the treatment symp- tomatic. If the itching is severe, dusting with starch will usually give relief 294 PRACTICE OF MEDICINE. Cerebro-Spinal Meningitis. Cerebro-Spinal Fever. Definition and Frequency.—A rather rare disease, prevailing as an epidemic and characterized anatomically by inflammation of the cerebral and spinal meninges. Causes.— I. A germ is almost certainly the essential cause, but it has not been isolated with absolute certainty. It is probable that it is a diplococcus similar to, if not identical with, that of lobar pneumonia (q. v.) 2 Noihing definite is known with respect to the favorable con- ditions of development or the avenues of introduction. 3. Age. The disease may occur at any age, but is more com- mon between ten and twenty. 4. It is very slightly contagious and defective hygienic conditions have little to do with its development or extension. Morbid Anatomy.—1 The meninges ofthe brain are inflamed and there is a purulent exudate which is especially marked around the vessels. The brain itself may be infiltrated and softened at certain spots. 2. The meninges of the cord are also inflamed; the roots of the spinal nerves are frequently affected in a similar way. 3. The liver, spleen, heart and kidneys show albuminoid degen- eration, from the action of the leucomaines. Symptoms.—1. The onset usually is sudden, but may be grad- ual and marked by stifiness in the back and shoulders and a feeling of malaise. 2. Nervous. The chief nervous symptoms in the early stages are headache, backache, stiffness of the back and possibly opistho- tonos, from the increased irritability of the sensory nerves and re- flexes, and vertigo and delirium, which are probably due to poison- ing by ptomaines. Convulsions are quite common, especially in young patients. At a later stage coma and paralysis appear, from the leucomaine poisoning and pressure of the exudate, or else from inflammation and destruction of nerve tissue. 3. Special senses. Photophobia, from increased sensibility of the sensory nerves; unequal pupils, from increased irritability or pres- sure of the exudate on some of the nerves; ptosis and strabismus, from the same cause, are common symptoms. Later on there may be pan-ophthalmitis. Deafness, from involvment of the acoustic nerve or from otitis media occurs in some cases. Loss of the sense of taste and smell is occasionally observed. 4. The temperature is usually but little elevated, but may be high. 5. The pulse is variable as to frequency and force, the variability being due probably to irregular nervous supply. PRACTICE OF MEDICINE. 295 6. The skin is hyperaesthetic f-om the increased sensibility of the sensory nerve roots and the nerve centres themselves, and there is an eruption of herpes on the lips and face in most cases. Some- times there is a macular or petechial rash also. 7. Nausea, vomiting and anorexia are nearly always observed and are probably central in origin. 8. Albuminuria is occasionally present, but well-marked nephri- tis is not common. Diagnosis.—i. From small pox by the absence of the charac teristic eruption of the latter disease. 2. From tubercular meningitis by the history of the case and the more marked spinal symptoms in epidemic meningitis. 3. From acute myelitis by the absence of the symptoms of irrita- tion (spasms and hyperaesthesia) in the latter. Prognosis.—The death rate is from 30 to 80 per cent. The prognosis is dependent on the age of the patient, the character and period of the epidemic and on the occurrence of complications. The duration is variable ; it is usually about two weeks, but the disease may last for months. Complications.— 1. Pulmonary. Lobar pneumonia is quite common in connection with this disease. Lobular pneumonia also occurs. 2. Cardiac. Attacks of sudden and alarming heart failure oc- cur, probably from defective supply of nerve force. Causes of Death.—1. Toxemia, from the abso ption of leuco- maines. 2. Coma, from pressure of the exudate or poisoning by leuco- maines. 3. Paralysis or spasm of respiratory muscles. 4. Asthenia, from defective supply of nerve force or from ex- haustion. 5. Complications (q. v ). Sequelae.— t Mental and nervous. Weakness of intellect and paralysis or paresis of certain muscles frequently result. 2. Special senses. Blindness, from pan-ophthalmitis, and deafness, from involvment of the acoustic nerve or from otitis media, are not uncommon sequelae. Treatment___A. Hygienic. The hygienic treatment is the same as that of typhoid fever. B. Medicinal. 1. To relieve pain bv quiet, opiates, phenacetine, bromides and cold or hot applications to the spine. 2 To relieve symptoms, such as thirst and constipation, by ap- propriate remedies. 296 PRACTICE OF MEDICINE. 3. To promote absorption, after the acute stage has passed, by iodide of potassium and blisters. 4. To sustain strength by nourishment and stimulants. Whooping Cough. (Pertussis.) Definition and Frequency.—An acute, infectious disease, of great frequency and characterized by attacks of violent coughing, spasmodic in character and attended by a peculiar whoop. Causes.— 1. A germ is almost certainly the essential cause, but it has not yet been tound. 2. The favorable conditions for development are (1) age of the patient—children under ten being far more liable to it than older persons ; and (2) previous health—it is especially common after epidemics of measles and in teething children. 3. The media of contagion are the air, and probably clothing ; the infectious agent is in the discharge from the air passages. 4. The avenue of introduction is the respiratory tract. 5. Immunity is conferred by one attack in nearly all cases. 6. The period of incubation is from five to fourteen days Morbid Anatomy.—The morbid anatomy is not characteristic. The bronchi are inflamed and the bronchial glands are usually en- larged. Symptoms.—A. In the 1st, or catarrhal stage, which lasts from one to three weeks, the symptoms resemble those of ordinary bronchitis. B. In the 2d, or spasmodic stage, there are attacks of violent coughing, in which the patient " loses his breath," and recovers it with a long-drawn inspiration or whoop. I omiting frequently occurrs duri-ng a paroxysm of coughing, and the face becomes livid. Occasionally there are extravasations of blood into the conjunc- tiva, which, however, are not serious. Urine and faeces may be passed involuntarily during a " fit" of coughing. This stage usually lasts about three zveeks, and is followed by the C. Third stage, or stage of decline, in which the symptoms giadually abate. This stage lasts from three to six weeks. PRACTICE OF MEDICINE, 297 Diagnosis.—The diagnosis is based on the prevalence of an epidemic and the character of the cough. Prognosis.—-The prognosis is usually favorable unless compli- cations arise. Complications. — 1. Pulmonary. Collapse of the lung and ca^ tarrhal pneumonia are very common. Emphysema is an occasional sequel and tuberculosis is quite a common sequel. 2. Nervous. Cerebral hemorrhage, with consequent paralysis, is a very rare complication. Treatment.—1. To lessen the violence of the paroxysms by belr ladonna, bromides, chloral, chloroform, musk, cocaine, carbolic acid by inhalation, antipyrine, phenacetine and quinine. 2. To improve the general health by arsenic and quinine and other tonics. 3. To prevent complications by the avoidance of cold and draughts, and especially of over-crowding. Fresh air is very im- portant, "Hydrophobia. (Rabies, when it occurs in animals.) Definition and Frequency.—An acute infectious disease, of great rarity in this country, characterized by peculiar spasms of the muscles of deglutition and sometimes of respiration. > Causes.—1. A virus, probably a germ, but the nature of the poison has not been definitely determined. 2. The avenue of introduction is always through the broken skin and the medium of conveyance is the saliva of a rabid animal. 3. The period of incubation is usually from three to six months. but it varies within still wider limits. Morbid Anatomy.—There is no characteristic morbid anato- my. Occasionally the nerve centers and the respiratory organs are found congested. Symptoms.—A. Incubative. Feverishness, loss of appetite and depression are the usual symptoms of the prodromic period. B. In the second or convulsive stage there are, at intervals of about half an hour, spasmodic contractions of the muscles of deglu- tition and respiration. The spasm of the muscles of deglutition is greatly increased by attempts to swallow; there is great thirst. The mind often remains clear, but occasionally delirium super- venes before death, 38 298 PRACTICE OF MEDICINE. Diagnosis.—1. From tetanus by the absence of trismus and opisthotonos and the more limited character of the convulsions. 2. From hysteria by the greater gravity of the symptoms. Prognosis.—The prognosis is nearly always bad. Causes of Death.—1. Asphyxia, from spasm of the respira- tory muscles. 2. Exhaustion, from inability to take food. Treatment—A. Preventive Inoculation, according to the method of Pasteur, with attenuated virus. The virus is obtained from the nervous matter, spinal cord usually, of a rabid animal. The virulence is diminished by keeping it, and the person who has been bitten is inoculated first with the most attenuated and subse- quently with virus of gradually increasing virulence. B. Remedial. Temporary ligation of the limb above the bitten point and sucking of the zvound to withdraw the virus is advisable. Curare has been used in a very few cases with success. Chloroform, chloral and other anti-spasmodics have been em- ployed without benefit. Dengue. (Dandy Fever. Breakbone Fever.) Definition.—An infectious disease, characterized by severe pain, fever and some swelling of the joints, and prevailing as an epidemic. Causes.—1. A germ is in all probability the essential cause. 2. The favorable conditions for development are zoarmth and slight elevation. It is but little, if at all, contagious and it is doubt- ful whether one attack confers immunity. 3. The period of incubation is from three to five days. Symptoms.—The general appearance is striking, from the stiff- ness of the muscles. 2. The nervous symptoms consist in violent pain, chiefly in the joints, but often in other parts of the body. The onset of these pains is usually sudden. 3. The temperature is elevated, often to 1040 or 1050, and the pulse is quick. 5. Anorexia is the rule, and nausea and vomiting occasionally occur. 5. The joints are swollen, tender and painful, and the glands are often enlarged. PRACTICE OF MEDICINE. 299 6. In many epidemics there is a rash resembling that of scarlet fever, but in many cases it is absent. 7. A remission occurs usually in from two to four days, which is followed by another paroxysm. Duration and Prognosis.—The usual duration of an attack is about eight days, but recurrences are frequent. The prognosis is almost uniformly favorable. Diagnosis.—1. From remittent fever by the greater intensity of the joint pain and the eruption. 2, From rheumatism by the epidemic character arid the involv- ment of the smaller joints. Treatment. — 1. To relieve pain by phenacetine, codeia, salicy- late of soda, &c. 2. To relieve symptoms, such as constipation and nausea. INDEX. A. PAGE. Abscess—hepatic...............148 of tonsils...............118 retro-pharyngeal,..........120 Acne,.....................232 " rosacea,.....r..........233 Addison's disease,..............210 Albuminuria, ................178 Alcoholism..................213 Anaemia—cerebral,..............262 " —general,..............205 —local,............... 5 ■' —progressive pernicious,........207 Aorta—aneurism of, .............176 Apoplexy..................270 Appendicitis,.................136 Arthritis deformans...............197 Ascites,...................143 Asthma—bronchial............... 85 Ataxia—locomotor, .............253 Atheroma,..................176 Athetosis,..................286 Atrophy,................. 24 " —progressive muscular,........259 B. Bacteria,.................. 33 Blood pressure—pathological relations of, ... . 11 Brain—topographical diagnosis in diseases of, . . . 267 Bright's disease................183 " —acute.............184 " —chronic............185 Bronchitis—acute,.............. 79 " —capillary,............. 81 —chronic,............ 80 " —croupous,............. 83 Bronchiectasis................. 84 C. Cancrum oris, ................ 115 §9 302 INDEX. Casts—renal, ................179 Catarrh—acute intestinal, ..........I 29 " —chronic intestinal,..........131 " —chronic nasal............. f>8 " —intestinal of children,.........134 Catalepsy,...... ...........278 Chicken-pox,................293 Chlorosis,..................205 Cholera—epidemic....... ....... 53 " infantum,...............133 " morbus,...............]33 Chorea,..................279 Chyluria,..................192 Constipation,..................l3^ Convulsions—infantile............277 Coryza—acute,.......>.......67 D. Degeneration—albuminoid, .......... 25 " —amyloid............. 27 —calcareous............ 27 —colloid,............ 25 —fatty,............. 26 —fibroid............. 28 " —mucoid,............ 25 " —parenchymatous,........ 25 Dengue..................298 Diabetes insipidus,.............205 mellitus,...............203 Diarrhcea...................129 Diphtheria,................. 47 Dropsy.................. 8 Dyesentery,................51 Dyspepsia,.................139 E. Eczema, ..................220 Electrical reactions—disturbances of in diseases of the nervous system,...........240 Embolism.................. 10 " —cerebral,..............272 Emphysema—pulmonary,........... 87 Empyema,..................104 Endocarditis, ................161 Enteritis—phlegmonous, ...........131 Epilepsy,..................275 Epistaxis,.................. 69 Erythema—intertrigo.............217 INDEX. 3°3 Erythema—multiforme,............217 —nodosum,.............218 —simplex,.............216 Exudate—nature of in inflammation,...... 15 Fever.................... 20 " —intermittent,............. 58 " —pernicious malarial........... f'3 " —relapsing,............... 44 " —remittent,............... 59 " —scarlet, ............... 44 " —typhoid................ ^6 " —typho-malarial,............ 60 " —typhus, ............... 42 " —yellow................. 55 Gall bladder—dropsy of,............T57 Gallstones..................!5o Gastralgia...................I28 Gastritis—acute................I21 " —chronic,..............I22 Glossitis...................Il6 Glottis—oedema of,............. 72 " —spasm of............... 72 Goitre—exophthalmic.............284 Gout.....................*99 H. Haematemesis,................ Haematuria.................l9l Haemophilia,................2I3 Heart—dilatation of,.............*7° —fatty degeneration of,..........l72 —functional disorders of,.........l7l —hypertrophy of,........... l69 —neuralgia of,.............!74 —valvular diseases of, . . .......l03 Hemorrhage—cerebral,..........270 —nasal,............. °9 Hepatitis—interstitial,.............H7 Herpes—zoster,............. Hives,............ Hodgkin's disease, .............. ^ Hydrocephalus—chronic,...........^7 Hydronephrosis, . . . • •.......' " 304 INDEX. Hydropericardium,..............161 Hydrophobia,...............297 Hydrothorax.................106 Hyperaemia—active............ 6 —cerebral.............261 —passive,............. 7 Hypertrophy,................ 24 Hysteria,..................277 I. Icthyosis...................227 Impetigo,..................221 Infarctions,................. 11 Inflammation,................ 13 Intermittent fever............... 58 Itch>....................235 J- Jaundice—catarrhal,.............155 K. K>dneys—acute inflammation of,........184 —chronic inflammation of,........185 —hyperaemia of,............182 —interstitial inflammation of,......187 —waxy degeneration of,........189 L. Laryngitis—acute catarrhal,.......... 69 " —chronic,............. 70 Larynx—paralysis of muscles of,........ 74 " —syphilis of,............. 73 " —tuberculosis of,............ 73 Leprosy...................2$i Leucocytes—function of in inflammation...... 14 —ultimate disposition of,....... 14 Leukaemia, ... .............208 Lichen—planus,..... ........222 " —ruber.................223 Liver—abscess of,....... ......148 —acute yellow atrophy of,.........150 " —amyloid degeneration of,.........151 " —cancer of,...............153 " —cirrhosis of,..............147 —fatty degeneration of,..........152 " —functional derangements of,.......154 " —hydatids of, ..............153 " -—hyperaemia of, . , , , ,.......145 INDEX. 305 Liver—interstitial inflammation of,........147 Lungs—collapse of,..............100 " —gangrene of............. 99 " —hyperaemia of,............ 96 " infarction of,.............. 98 " —oedema of,.............. 97 Lupus—erythematosus,............230 " —vulgaris,...............229 M. Malarial diseases................ 57 —toxaemia......... .... 64 Measles, ..................287 " —German,..............289 Meningitis—acute spinal,........... 248 —cerebral,...... ......263 —cerebro-spinal,...........294 " —simple acute,...........264 " —tubercular,............266 Morphcea,..................228 Motion—disturbances of in diseases of the nervous system,................237 Mumps.................... 65 Myalgia,..................198 Myelitis—acute and chronic,.........250 Myocarditis,.................171 N. Neuralgia, .................243 " —intercostal, ............247 —sciatic, . . . . "..........246 -rtrifacial,.............245 Neurasthenia,................282 Neuritis—simple and multiple,.........241 Noma....................I!5 Nutrition—disturbances of in diseases of the nervous system,................239 O. CEsophagus—diseases of,...........121 Osteomalacia,................202 P. Pachymeningitis—internal,........... 263 Pancreas—diseases of,.............158 Paralysis—acute cerebral of children,......273 « —agitans, . . ...........280 f« —bulbar, ........ , . • • • 257 306 INDEX. Paralysis—facial................243 " —general—of the insane........274 —infantile..............258 " —pseudohypertrophic.........260 " —spastic spinal.............255 Pemphigus..................226 Pericarditis..................159 Perichondritis—laryngeal...........71 Perihepatitis,................ 146 Peritonitis—acute............. . 140 " —chronic..............142 Perityphlitis..................136 Pernicious malarial fever,........... 63 Pharyngitis—catarrhal.............117 " —chronic,.............119 Phthisis—pulmonary,.............106 Physical diagnosis,.............. 74 Pityriasis rubra,...............224 Pleurisy—acute,...............102 " —sub-acute (or serous)..........103 Pneumonia—acute lobar, ........... 89 " —lobular.............. 93 Pneumothorax,................105 Poliomyelitis—acute anterior,.........258 Prurigo,................ . 224 Pseudo-leukaemia..............209 Psoriasis........ .........225 Purpura........„..........212" Pyelitis,................... 190 Pylephlebitis......m...........151 R. Reflexes—disturbances of in diseases of the nervous system.................238 Relapsing fever................ 44 Remittent fever................ 60 Renal diseases—circulatory changes in, .... 181 Rheumatism—acute articular,.........195 " —chronic articular........ . 197 " —inflammatory,.........\ 195 —muscular,............198 Rickets,....................202 Ringworm,................. 234 S. Scabies....................235 Scarlet fever,........^......... 44 Sciatica....................246 INDEX. 307 Scleroderma,.................228 Sclerosis—amyotrophic lateral,........256 —insular or disseminated,.......252 —lateral spinal,............255 —posterior spinal............253 Scurvy,............... \ . . 211 Sea sickness, . •................284 Secondary degenerations,...........239 Sensation—disturbances of in diseases of the nervous system,........, .......238 Shingles...................226 Sick headache................. 283 Small-pox, .................290 Spinal cord—classification of diseases of,.....249 « «« —general symptomatology of diseases ot, 250 Spleen—diseases of,..............158 Stomach—cancer of,.............124 —dilatation of,............127 —ulcer of,..............125 Stomatitis—aphthous,.............114 " —simple...............112 " —ulcerative,...........113 Sunstroke,.................281 Sycosis,...................234 T. Tetany,...................285 Thrombosis,..........•...... 9 " —cerebral,............272 Thrush,......... .........IJ5 Tinea—circinata,...............234 Tonsillitis—follicular,.............117 Tonsils—abscess of,..............118 " —enlarged,..............ll9 Trichinosis,.................x38 Trophic lesions,...............239 Tubercle,.................. 29 Tuberculosis, .........••••'•••■ 29 " —acute,............. 32 « —pulmonary,...........io7 Tumors—cerebral,..............269 Typhlitis,..................J3° Typhoid fever................. 3° Typho-malarial fever,............. OI Typhus fever,................ 42 U. Uraemia—acute, 18Q 308 INDEX. Urinary deposits............... . 194 Urine—morbid conditions ol...........193 " —nocturnal incontinence of,........192 Urticaria,.................219 V. Vaccination,.................292 Variola,...................290 Varioloid,..................292 W. Whooping cough...............296 Worms—intestinal,..............137 Writer's cramp,...............280 Y. Yellow fever,................ 55 Z. 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